Cancer Cytogenetics

CANCER CYTOGENETICS

CANCER CYTOGENETICS ~

THIRD EDITION

Edited by

Sverre Heim Department of Medical Genetics Oslo University Hospital, Norway

Felix Mitelman Department of Clinical Genetics Lund University Hospital, Sweden

@WILEY-BLACKWELL A JOHN WILEY &SONS, INC., PUBLICATION

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Copyright

2004 by John Wiley & Sons, lnc. All rights reserved

Wiley-Blackwell is an imprintof John Wiley & Sons, formed by the mergerof Wiley’s global Scientific. Technical,and Medical business with Blackwell Publishing. Published by John Wiley & Sons, lnc., Hoboken. New Jersey Publishedsimultaneouslyin Canada No partof this publicationmay be reproduced.storedin a retrievalsystem,or transmittedin any formor by any means,electronic,mechanical, photocopying, recording,scanning,or otherwise,except as permittedunder Section 107 or 108 of the 1976 United StatesCopyrightAct, withouteitherthe priorwrittenpermissionof the Publisher,or authorizationthroughpaymentof the appropriateper-copy fee to the CopyrightClearanceCenter, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4470, or on the web at www. copyright.com.Requeststo the Publisherfor permissionshould be addressedto the Permissions Department, JohnWiley & Sons, Inc., I I I RiverStreet,Hoboken,NJ 07030, (201) 748-601 I , fax (201) 748-6008, or online at http://www.wiley.com/go/permission.

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CONTENTS

Preface Contributors

1. A New Approachto an Old Problem

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ix 1

Sverre Heim and Felix Mitelman

2. CytogeneticMethods

9

David Gisselsson

3. CytogeneticNomenclature

17

Sverre Heim and Felix Mitelman

4. NonrandomChromosomeAbnormalitiesin Cancer-An Overview

25

Sverre Heim and Felix Mitelman

5. Acute Myeloid Leukemia

45

Bertil Johanssonand ChristineJ. Harrison

6. MyelodysplasticSyndromes Harold J. Olney and Michelle M.Le Beau

141

7. ChronicMyeloid Leukemia

179

Thoas Fioretos and Bertil fohunsson

8. ChronicMyeloproliferativeNeoplasms

209

Peter Vandenberghe,LucienneMichux,and Anne Hagemeijer

9. Acute LymphoblasticLeukemia

233

ChristineJ. Harrison and Bertil Johansson

10. MatureB- and T-cell Neoplasmsand Hodgkin Lymphoma

297

Reiner Siebert

11. Tumorsof the Upper AerodigestiveTract

375

MihaelaAvramutand SusanneM. Gollin

12. Tumorsof the Lung

415

Penny Nymark,Eeva Kettunen,and Sakari Knuutila

13. Tumorsof the Digestive Tract

429

Georgiu Bardi and Sverre Heim

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CONTENTS

14. Tumors of the Urinary Tract Paola Dal Cin and Azra H. Ligon

463

15. Tumors of the Breast

493

ManuelR. Teixeira,Nikos Pandis, a d Sverre Heim

16. Tumors of the Female Genital Organs

519

Francesca Micci and SverreHeim

17. Tumors of the Male Genital Organs

557

ManuelR. Teixeiraand Sverre Heim

18. Tumors of Endocrine Glands

577

J6m Bullerdiekand David Gisselsson

19. Tumors of the Nervous System

597

AaronM. Bender,Fausdo J. Rodriguez GobindaSarkar,and RobertB. Jenkins

20. Tumors of the Eye

621

KarenSisley

21. Tumors of the Skin

641

FredrikMertensand SverreHeim

22. Tumors of Bone

655

FredrikMertensand Nils Mandahl

23. Soft Tissue Tumors

675

Nils MandahIand FredrikMertens

Index

713

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PREFACE

Since the publicationof the secondeditionof CancerCyzogenetics more than 10yearsago, the field has made gigantic strides forward.Many more cases have been examined, especially among the solid tumors,and yet this is not the most importantchange. It is the increasingutilizationof several novel techniquesin the borderzone between cytogenetics, as we used to know it, and moleculargenetics that has made the greatestimpact; hardlya week passes withoutsome new cancer-associatedgene fusion correspondingto a chromosomalrearrangement, be it specific or not, is identifiedand the genes cloned. As a result,ourcurrentknowledgeof the molecularpathogenesisof cancervastly surpasseswhat was known a decade ago, and the growth rate is not abating.The efforts attemptingto correlatethe new findingswithclinico-pathologicalparametersareunableto keeppacewith the molecularprogressfilling the pages of electronicas well as more traditionalscientific journals.And in the midst of all this molecularand molecularcytogenetic inventiveness, chromosomebandinganalysis retainsits position as the robustmethodologicalbackbone against which all other analyticalapproachesmust be measured,still providingthe most directand unbiasedoverview of the acquiredgenomic aberrationsof tumorcells both in terms of the dominantclones and whatevercell-to-cell variabilitymay exist within the neoplastic parenchyma. Although the second edition of Cancer Cytogenetics could still be written by two authors,this was clearly too much for the third edition. No less than 31 experts have writtenthe 23 chaptersof this edition, and we are profoundlygratefulto all of them for their contributions;we know that their level of expertise in each respective subfield outstripsthatof the two editors.Multipleauthorshipinvariablyleads to a more heterogeneous book in spite of ourefforts to impose a common style and structureto all chapters; however,we choose to see this heterogeneityas an advantageratherthan a defect, given the variability in viewpoints as well as methodological approachesthat characterizes modern cancer cytogeneticists, not to mention members of the scientific community at large. This third edition of Cancer Cytogenetics contains much more molecular genetic informationthandidthe previouseditionsandis twice the size of its immediatepredecessor, but makesno claim to cover in at least a semicompletemannermore thanthose molecularlevel changes that arise through chromosomal aberrations.The book also strives to emphasizeclinical correlationswheneverthese are known;we sincerely hope that it will proveuseful also for the clinicianswho careforcancerpatientsandwho may not alwaysbe able to keep abreastwith the latestcancercytogeneticnews stories.We areconvincedthat theclinical usefulnessof cancercytogeneticswill continueto grow, not only diagnostically and prognosticallybut also by paving the way for novel medications that counteract specificallythe very geneticalterationsthatunleashneoplasticbehaviorin eachtumortype. In this manner,cytogeneticswill contributeto a new cancer medicine that is both rational vii

Vili

PREFACE

and individualized, based, as it must be, on a precise and detailed knowledgeof the genomic rearrangements of the tumor cells. A more appropriate way of celebrating the impending 100th anniversary of Theodor Boveri’s somatic mutation theory of cancer is hard to envisage. SVERRE HEW FELIXMITELMAN Oslo and Lund 2008

Mihaela Avramut, Departmentof Pathology,Universityof PittsburghSchoolof Medicine, Pittsburgh,PA, USA Georgia Bardi, BioAnalytica-GenoTypeSA, Athens, Greece Aaron M. Bender, Division of LaboratoryGenetics,Mayo Clinic Rochester,MN, USA

Jorn Bullerdiek, Centerfor HumanGenetics,Universityof Bremen,Bremen,Germany Paola Dal Cin, Departmentof Pathology,Brighamand Women’sHospital,Boston, MA, USA Thoas Fioretos, Departmentof Clinical Genetics, Universityof Lund,Lund, Sweden David Gisselsson, Departmentof Clinical Genetics,Universityof Lund,Lund,Sweden Susanne M. Gollin, Departmentof HumanGenetics,Universityof PittsburghSchool of Medicine, Universityof PittsburghCancerInstitute,Pittsburgh,PA, USA Anne Hagemeijer, Centrefor HumanGenetics, Universityof Leuven,Leuven,Belgium Christine J. Harrison, LeukaemiaResearchCytogeneticsGroup,NorthernInstitutefor CancerResearch,Newcastle University,Newcastle upon Tyne, UK Sverre Heim, Departmentof Medical Genetics,The NorwegianRadiumHospital, Oslo University Hospitaland Medical Faculty,Universityof Oslo, Oslo, Norway Robert B. Jenkins, Division of LaboratoryGenetics,Mayo Clinic Rochester,MN, USA Bertil Johansson, Departmentof ClinicalGenetics,Universityof Lund, Lund,Sweden Eeva Kettunen, Departmentof HealthandWorkAbility,FinnishInstituteof Occupational Health, Helsinki,Finland Sakari Knuutila, Departmentof Pathology,HaartmanInstituteandHUSLAB,University of Helsinki and Helsinki UniversityCentralHospital,Helsinki,Finland Michelle M. Le Beau, Universityof Chicago,Sectionof Hematology/Oncology,Chicago, IL, USA Azra H. Ligon, Departmentof Pathology,Brighamand Women’s Hospital,Boston, MA, USA Nils Mandahl, Departmentof Clinical Genetics, Universityof Lund,Lund,Sweden Fredrik Mertens, Departmentof ClinicalGenetics,Universityof Lund,Lund,Sweden

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CONTRIBUTORS

Francesca Micci, Departmentof Medical Genetics, The Norwegian Radium Hospital, Oslo UniversityHospital,Oslo, Norway Lucienne Michaux, Centrefor HumanGenetics,Universityof Leuven, Belgium Felix Mitelman, Departmentof Clinical Genetics,Universityof Lund, Lund,Sweden Penny Nymark, Departmentof HealthandWorkAbility,FinnishInstituteof Occupational Health and Departmentof Pathology, HaartmanInstitute, University of Helsinki, Helsinki,Finland Harold J.Olney, Universitkde Montrkal,CentreHospitalierde 1’UniverstiCde Montrhl (CHUM),Montreal,Quebec,Canada Nikos Pandis, Departmentof Genetics, Saint Savas Hospital,Athens, Greece Fausto J.Rodriguez, Division of LaboratoryGenetics,MayoClinicRochester,MN, USA Gobinda Sarkar, Division of LaboratoryGenetics, Mayo Clinic Rochester,MN, USA Reiner Siebert, Institute of Human Genetics, Christian-Albrechts-Universitit,Gel, Germany Karen Sisley, AcademicUnit of Ophthalmologyand Orthoptics,School of Medicineand BiomedicalSciences, Universityof Sheffield, UK Manuel R. Teixeira, Departmentof Genetics. PortugueseOncology Institute,Porto. Portugal Peter Vandenberghe, Centre for Human Genetics, University of Leuven, Leuven, Belgium

A New Approach to an Old Problem SVERRE HEIM and FELIX MITELMAN

Theroleof geneticchangesin neoplasiahasbeen a matterof debatefor morethan100years. The earliestsystematicstudyof cell division in malignanttumorswas made in 1890 by the GermanpathologistDavid von Hansemann.He drewattentionto the frequentoccurrenceof aberrantmitosesin carcinomabiopsiesandsuggestedthatthisphenomenoncould be used as a criterionfor diagnosingthe malignantstate. His investigationsas well as other studies associatingnuclearabnormalitieswith neoplasticgrowthwere, a quarterof a centurylater, forgedintoa systematicsomaticmutationtheoryof cancer,which was presentedin 1914 by Theodor Boveri in his famous book Zur Frage der Entstehung mahgner Tumoren. According to Boveri’s hypothesis, chromosomeabnormalitieswere the cellular changes causingthe transitionfrom normalto malignantproliferation. Fora long time, Boveri’sremarkablyprescientidea,theconceptthatneoplasiais brought aboutby an acquiredgenetic change,could not be tested.The study of sectionedmaterial yielded only inconclusive results and was clearly insufficient for the examinationof chromosomemorphology.Technical difficultiesthus preventedreliable visualizationof mammalianchromosomes,in both normaland neoplasticcells, throughoutthe entirefirst half of the twentiethcentury. Duringthese “darkages” of mammaliancytogenetics(Hsu, 1979), plantcytogeneticists made spectacularprogress,very much throughtheiruse of squashand smearpreparations. Thesetechniqueshadfrom 1920onwardgreatlyfacilitatedstudiesof the geneticmaterialin plantsand insects,disclosingchromosomestructuresmorereliablyandwith greaterclarity than had been possible in tissue sections. Around 1950 it was discovered that some experimentaltumorsin mammals, in particularthe Ehrlichascites tumor of the mouse, could also be examinedusing the same squashand smearapproach.These methodswere then rapidlytriedwith othertissues as well, and in generalmammalianchromosomeswere found to be just as amenableto detailedanalysis as the most suitableplant materials. Simultaneously,tissue culturingbecamemorewidespreadand successful,one effect of which was thatthe cytogeneticistsnow hadat theirdisposala stablesourceof in vitro grown cells. Of crucial importancein this context was also the discovery that colchicine pretreatmentresulted in mitotic arrestand dissolution of the spindle apparatusand that treatmentof arrestedcells with a hypotonicsalt solution greatly improvedthe quality of

Cancer Cyrogenetics, Third Edition, edited by Sverre Heim and Felix Mitelman Copyright Q 2009 John Wiley & Sons, lnc.

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A NEW APPROACH TO AN OLD PROBLEM

metaphasespreads.Individualchromosomescouldnow be countedandanalyzed.Themany methodological improvementsushered in a period of vivid expansion in mammalian cytogenetics, culminatingin the descriptionof the correctchromosomenumberof man by Tjio and Levan (1956) and,shortlyafterward,the discoveryof the majorconstitutional human chromosomalsyndromes. Two technical breakthroughsaround the turn of the decade were of particularimportance:the finding that phytohemagglutinin(PHA) has a mitogeniceffect on lymphocytes(Nowell, 1960) and the developmentof a reliablemethod for short-termculturingof peripheralblood cells (Moorheadet al., 1960). Cytogeneticstudiesof animalascites tumorsduringthe early 1950s, followed soon by investigationsof malignantexudatesin humans(Fig. 1. I), uncoveredmany of the general principles of karyotypic patternsin highly advanced, malignant cell populations:the apparentlyubiquitouschromosomalvariabilitywithin the tumorsurmisedby pathologists since the 1890s; the stemlineconcept,firstdefinedby Winge (1930); and the competition between stemlinesresultingin labile chromosomalequilibriaresponsiveto environmental alterations.The behavior of malignant cell populations could now be described in Darwinianterms: by selective pressures,a dynamic equilibriumis maintained,but any environmentalchange may upset the balance, causing shifts of the stemline karyotype. Evolutionthusoccursin tumorcell populationsin muchthe samemanneras in populations of organisms: chromosomal aberrationsgenerate genetic diversity, and the relative “fitness” impartedby the various changes decides which subcloneswill prevail.

FIGURE 1.1 Camera lucida drawing of tumor cell mitosis from one of the first (early 1950s) human cancerous effusions submitted to detailed chromosome analysis. The modal number was 75. The stemline also contained numerous abnormal chromosome shapes (Courtesy of Prof. Albert Levan, 1985).

A NEW APPROACH TO AN OLD PROBLEM

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The elucidationof these evolutionaryprinciplesin numerous studiesby a numberof investigators,for example,Hauschka( 1953), Levan (1956), and Makino(1956), paved the way for the new and growingunderstandingof the role of karyotypicchangesin neoplasia and laid the foundationof modem cancer cytogenetics. In humans as well as in other mammals,the resultsstronglyindicatedthatthechromosomalabnormalitiesobservedwere an integralpartof tumordevelopmentand evolution (see, e.g., Levan, 1967; Koller, 1972; Hsu, 1979;Sandberg,1980, forreviewof the earlydata).It shouldbe keptin mind,however, thatthe object of these early investigationswas always metastatictumors,often effusions, thatis, highly malignantcell populations.Hence, few, if any, conclusionscould be drawn from them as to the role of chromosomalabnormalitiesin early tumorstages. Interestin cancer cytogenetics influencedhumancytogenetics much more profoundly thanis currentlyappreciated.For example,the main goal behindthe studythateventually led to the descriptionof the correctchromosomenumberin man(Tjioand Levan, 1956) was to identifywhatdistinguisheda cancercell. The motivationwas not primarilyan interestin the normalchromosomeconstitution,which at thattime had no obvious implications,but thehopethatsuchknowledgewouldhelpanswerthe basicquestionof whetherchromosome changes lay behindthe transformationof a normalto a cancercell. The first spectacularsuccess in cancer cytogeneticscame when Nowell and Hungerford (1960) discovered that a small karyotypicmarker(Fig. 1.2), the Philadelphia(Ph)

FIGURE 1.2 Unbanded metaphasecell from a bone marrow cultureestablished from a patient with chronic myeloid leukemia. The arrow indicates the Ph chromosome (previously called Ph’). The superscript number I indicated that this was the first cancer-specificaberrationdetected in Philadelphia. This naming practice was later abandoned, but the abbreviation Ph has been retained for sentimental reasons, since it was the first consistent chromosome abnormality detected in a human malignancy.

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chromosome,replaced one of the four smallest autosomes (the G-groupchromosomes accordingto the nomenclatureat the time) in the bone marrowcells of seven patientswith chronicmyeloid leukemia(CML).Thiswas the firstconsistentchromosomeabnormalityin a humancancer,andits detectionseemedto provideconclusiveverificationof Boveri’sidea. It was reasonable to assume that the acquired chromosomal abnormality-a perfect exampleof a somaticmutationin a hematopoieticstem cell-was the directcause of the neoplasticstate. Nowell andHungerford’sdiscoverygreatlystimulatedinterestin cancercytogeneticsin the early 1960s. but for several reasonsthe Ph chromosomelong remainedan exceptional finding.The confusing plethoraof karyotypicaberrationsencounteredin othermalignancies suggested that the changes were epiphenomenaincurredduringtumorprogression ratherthanessentialearlypathogeneticfactors.The enthusiasmfor tumorcytogeneticsas a result graduallyfaded. With this change of mood, the perceived significanceof the Ph chromosomealso changed,and the very uniquenessof the markercame to be regardedas a perplexingoddity.Why shouldtherebe such a simple associationbetweena chromosomal traitand one particularmalignantdisease when moreand moredatafrom otherneoplasms showed either no chromosome aberrationsat all or a confusing mixtureof apparently meaninglessabnormalities? Thatan orderlypatternexisted in what had hithertobeen seen as chaos was suggested independently in the mid-1960s by Levan (1966) and van Steenis (1966). Surveying chromosomaldataavailablein the literature,mainly on ascitic formsof gastric,mammary, uterine,and ovariancarcinomas,they foundclear evidence thatcertainchromosometypes tended to increaseand others to decrease in numberin the tumors.Soon afterward,the nonrandomnessof karyotypicchanges was also demonstratedbeyond doubt in specific typesof humanhematologicdisordersandsolid tumors,forexample,deletionof an F-group chromosome in polycythemia Vera (Kay et al., 1966), loss of a G chromosome in meningioma(Zangand Singer, 1967). and a C-G translocationin acutemyeloid leukemia (Kamadaet al., 1968). The results of comprehensivecytogenetic studiesof experimental tumors,includingmore than200 primarysarcomasinducedby Rous sarcomavirusin four species of animals,supportedthe same conclusion(Mitelman,1974). In both humansand animals, the karyotypicabnormalitiesseemed to be of two essentially differentkinds: nonrandomchangespreferentiallyinvolvingparticularchromosomesanda frequentlymore massive random or backgroundvariation affecting all chromosomes. To differentiate between the two could be exceedingly difficult, however. As a consequence,in spite of painstakingefforts, little progresswas made in cancer cytogeneticsduringthis period. The situation changed dramaticallyin 1970 with the introductionof chromosome bandingtechniquesby Casperssonand Zech (Casperssonet al., 1970). The new methodology completely revolutionizedcytogenetic analyses. Each chromosomecould now be precisely identifiedon the basis of its uniquebandingpattern;whereasformerlyidentification was restrictedto chromosome groups, all descriptionsof chromosomedeviations immediatelybecamemore preciseand the conclusionsbased on them more stringent.The first neoplasia-associated chromosome abnormalities characterized by banding were published in 1972: monosomy 22 in meningioma(Mark et al., 1972; Zankl and Zang, 1972), trisomy 8 in acute myeloid leukemia(de la Chapelleet al., 1972), a 14q markerchromosomein Burkittlymphoma(ManolovandManolova,1972), anddeletionof the long arm of chromosome20 (2Oq-) in polycythemiaVera (Reeves et al., 1972). The following year,Rowley (1973) showedthatthe Ph chromosomein CMLwas the resultof a translocationbetween chromosomes9 and 22, not a deletion of chromosome22 as was

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A NEW APPROACH TO AN OLD PROBLEM

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previously thought.The 9;22-translocationthus became the first example of an acquired balanced rearrangementin neoplasia, but soon afterwardsimilar consistent and even specific cancer-associatedchromosomeaberrationswere disclosed in a wide variety of neoplasticentities among the hematologicmalignanciesand duringthe following decade also in solid tumors. The advent of moleculargenetics in the 1980s and the developmentof a range of powerfulmolecularcytogenetictechnologiesduringthe last two decades,such as fluorescence in situ hybridization(FISH), multicolorFISH, and chromosomaland array-based comparativegenomic hybridization(CGH) (Keamey and Horsley, 2005; Pinkel and Albertson,2005; Speicherand Carter,2005), combinedwith rapidprogressalso in other areas of cell and tumor biology, have dramaticallywidened our knowledge and understanding of the molecular mechanisms that are operative in neoplastic initiation and progression.The new techniqueshave enabled researchersto investigatetumorcells at the level of individualgenes, even at the level of single base pairs, and the molecular consequencesof an ever-increasingnumberof cancer-associatedchromosomeaberrations have thus been laid bare. The newly reachedmolecularinsightsinto two of the first and most distinctivecancerspecificchromosomaltranslocations-the t(9;22)(q34;qlI ) of CMLthatfuses the BCR and ABLl genes, and the t(8;14)(q24;q32)of Burkitt lymphoma that juxtaposes the MYC oncogene with the immunoglobulinheavy-chaingene (fGH)-stimulated an enormous interestin cancer cytogenetics as a powerful means to pinpoint the locations of cancerinitiating genes (Heim and Mitelman, 1987). As a consequence, the information on chromosomeaberrationsin neoplasia has steadily increased over the past two decades, and the total numberof tumorcases in which clonal cytogeneticabnormalitieshave been reportednow exceeds 55,000, publishedin morethan12,000articles(Mitelmanet al., 2008). To date, more than400 genes in the breakpointshave been found to be rearrangedandor deregulatedas a consequence of a chromosomalchange in neoplasia (Mitelman et al., 2007). It is obvious that cross-fertilizationbetween cytogenetics and moleculargenetics has led to conceptually new advances and insights into the fundamental cell biology mechanismsthatare disruptedwhen neoplastictransformationoccurs. At the same time, the clinical usefulness of cytogenetic abnormalitiesas diagnostic and prognosticaids in cancer medicine has been increasingly appreciated.The ultimate goal is to arrive at specific therapies individualized to counter those molecular mechanisms that have gone awry in each patient’s cancerous disease. The development of imatinib (Druker,2004) as a therapeuticagent for CML-the first example of a targetedtherapy against a specific fusion gene in cancer-is a wonderful example of how progress in cytogenetics and molecularbiology has led to a qualitativelynew treatmentapproach:the discovery of the Ph chromosome, the finding that the Ph chromosome results from a reciprocal translocation,the identificationof the two genes in the breakpointsof the translocation,and the subsequentcharacterizationof the fusion gene and its protein product.We are convinced that many similar success stories are unfolding as we write; cancergeneticresearchhelps obtainmoreeffective andless toxic treatmentsformalignant diseases. Thus, in the little over 100 years since von Hansemann’sinitial report,cancer cytogenetics has come of age. It is no longer a purely descriptivediscipline but one that attemptsto synthesize informationfrom several investigativeapproaches.Cancercytogenetics hasbecome both acentralmethodologyin basic cancerresearchandan important clinical tool in oncology.

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REFERENCES Boveri T (1914): Zur Frage der Entstehung maligner Tumoren. Jena,Germany:Gustav Fischer. CasperssonT, Zech L, JohanssonC (1970): Differentialbindingof alkylatingfluorochromesin human chromosomes.Exp Cell Res 60:3 15-319. de la Chapelle,A, SchroderJ, Vuopio P (1972): 8-Trisomyin the bone marrow.Reportof two cases. Clin Genet 3:470-476. DrukerBJ (2004): Imatinibas a paradigmof targetedtherapies.Adv Cancer Res 9 I: 1-30. HauschkaTS (1953): Cell populationstudieson mouse ascites tumors.Ann NY Acad Sci 16:64-73. Heim S, MitelmanF ( I 987): Cancer Cytogenetics. New York Alan R. Liss, Inc. Hsu TC (1979): Human and Mammalian Cytogenetics. A Historical Perspective. New York: Springer-Verlag . KamadaN, Okada K, It0 T, Nakatsui T, Uchino H (1968): Chromosomes21-22 and neutrophil alkalinephosphatasein leukaemia.Lancet I :364. Kay HEM, LawlerSD, MillardRE (1966): The chromosomesin polycythemiaVera.5 r J Haematol 12:507-527. Keamey L, Horsley SW (2005): Molecular cytogenetics in haematological malignancy:current technology and futureprospects.Chromosoina 1 14:28&294. KollerPC (1972): The Role of Chromosomes in Cancer Biology. Recent Results in Cancer Research, Vol. 38. Berlin: Springer-Verlag. Levan A ( I 956): Chromosomalstudieson some humantumorsandtissuesof normalorigin,grownin vivo and in vitro at the Sloan-KetteringInstitute.Cancer 9:648-663. Levan A (1966): Non-randomrepresentationof chromosome types in human tumor stemlines. Hereditas 55:28-38. Levan A ( 1967): Some currentproblemsof cancercytogenetics.Hereditas 57:343-355. MakinoS (1956): Furtherevidencefavoringthe conceptof the stemcell in ascitestumorsof rats.Ann NY Acad Sci 63:8 18-830. Manolov G, Manolova Y (1972): Markerband in one chromosome 14 from Burkittlymphomas. Nature 237:33-34. MarkJ, Levan G, MitelmanF (1972): Identificationby fluorescenceof the G chromosomelost in human meningomas.Hereditus 7 1 :163-168. Mitelman F ( 1 974): The Rous sarcoma virus story: cytogenetics of tumors induced by RSV. In: GermanJ, editor. Chromosomes and Cancer. New York: John Wiley & Sons, pp 675-693. MitelmanF, JohanssonB, MertensF (2007): The impactof translocationsandgene fusionson cancer causation.Nut Rev Cancer 7:233-245. MitelmanF, JohanssonB, MertensF, editors(2008):MitelmanDatabaseof ChromosomeAberrations in Cancer.Available at http://cgap.nci.nih.gov/Chromosomes/Mitelman. Moorhead PS, Nowell PC, Mellman WJ, Battips DM, HungerfordDA (1960): Chromosome preparationsof leukocytesculturedfrom human peripheralblood. Exp Cell Res 20:613-616. Nowell PC ( I 960): Phytohemagglutinin:an initiator of mitosis in cultures of normal human leukocytes.Cancer Res 20:462-466. Nowell PC, HungerfordDA ( 1960):A minutechromosomein humanchronicgranulocyticleukaemia. Science 132:1497. Pinkel D, Albertson D (2005): Array comparativegenomic hybridizationand its applicationsin cancer.Nat Genet 37:s 1 1 -S 17 Reeves BR, LmbbDS, LawlerSD (1 972): Identityof the abnormalF-groupchromosomeassociated with polycythaemiaVera. Humangenetik 14: 159-161.

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Rowley JD (1973): A new consistentchromosomalabnormalityin chronicmyelogenous leukaemia identifiedby quinacrinefluorescenceand Giemsastaining.Nature 243:29&293. SandbergAA (1 980): The Chromosomes in Human Cancer andleukemia. New York:ElsevierDIorthHolland. Speicher MR, CarterNP (2005): The new cytogenetics:blurringthe boundarieswith molecular biology. Nat Rev Genel 6:782-792. Tjio JH, Levan A (1956): The chromosomenumberof man. Hereditas 42: 1-6. van Steenis H (1966): Chromosomesand cancer.Nature 2093 19-821. von HansemannD ( I 890): Ueber asymmetrischeZelltheilungin Epithelkrebsenund deren biologische Bedeutung.Virchows Arch Anat 1 19:299-326. Winge0 ( I 930): ZytologischeUntersuchungeniiberdie NaturmalignerTumoren.II.Teerkarzinome bei Mausen.Z fillforsch Mikrosk Anat 10683-735. Zang KD, SingerH ( 1967): Chromosomalconstitutionof meningiomas.Nature 21 6:84-85. Zankl K, ZangKD (1972): Cytological and cytogeneticalstudieson braintumors.4. Identificationof the missing G chromosome in human meningiomas as no. 22 by fluorescence technique. Humangenetik 14:167- 1 69.

Cytogenetic Methods DAVID GISSELSSON

The humanchromosomecomplementconsistsof 22 pairsof autosomesandone pairof sex chromosomes,XX in females and XY in males. The autosomesare numberedaftertheir relative lengths, with the exception of chromosomes21 and 22. For stable functionof a chromosome,a centromere somewherealong its length and a telomere at each terminus are required.The centromereis associated with the kinetochoreproteincomplex necessary for anchoringof the spindle fibers and for separationof sister chromatidsat the metaphase-anaphasetransition.Centromericregions contain Large areas of repetitive DNA sequences, some of which contributeto the segments of constitutive heterochromatin found aroundthe centromeresof all chromosomes, though most prominentlyin 1, 9, 16, and Y. Another type of repetitive DNA element is located at the telomeres. These tandemly repeated TTAGGG hexamer units maintain the structuralintegrity of chromosometermini and ensure complete replicationof the most terminalnonrepetithe sequences. Immediatelyproximalto the telomeric repeats,a set of more complex, subtelomeric repeats are found. Similar to the centromeric repeats, the structureof the subtelomericsequences varies so that most of the humanchromosomearms exhibit unique sequences. Since the correctchromosomenumberof man was reportedhalf a centuryago (Tjio and Levan, 1956), our possibilities to analyze the human chromosome complement have improvedsteadily.This chapteris an attemptto outline the methodscurrentlyemployed in cancer cytogenetics, spanningfrom chromosomebanding to array-basedtechniques. Cytogenetic methods have traditionallybeen based on microscopic examination of individual cells and it can be argued that array-basedmethods are not cytogenetics. However, also these techniquesaim to describe chromosomestructureand number,and few tumorcytogenetic studies published today rely solely on microscopicexamination (Speicherand Carter,2005). It is thereforenaturalto include an outline of array-based techniquesin this chapter.The practicaldetails and protocolsof the specific methodswill only be touched upon and the reader is referredto the individualarticles cited in later chaptersfor more detailed information.

Cancer Cytogenetics, Third Edirion, edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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CYTOGENETIC METHODS

SAMPLING FOR CYTOGENETIC ANALYSIS A correctsamplingprocedureis thebasisforcorrectscientificanddiagnosticconclusions.A first issue to consider is whether the sample is sufficient for the planned analyses. Chromosomepreparationrequireslive cells, whereasin situ hybridizationat leastrequires intact nuclei, and comparativegenome hybridizationrequiresDNA that has not been extensivelydegraded.Anotherissue to consideris whetherthe sampleis representativeof the neoplastic lesion to be investigated.Cytogeneticistsrarelyknow precisely which cells they study.Exceptionsto this arewhen in situ hybridizationis combinedwith immunohistochemical staining of intact cells or when DNA is extractedfor analysis either from microdissected solid tumor components or from flow-sorted cells. When analysis is performedon culturedcells, it is thereforeimportantto considerwhetherthe resultsare representativeof the in vivo situation.Two main types of heterogeneity canbe expectedat cytogeneticanalysisof a tumorsample:that between neoplasticand non-neoplasticcells, and thatamongvariousneoplasticcells (Pandiset al., 1994).In vitro overgrowthof normal cells or of neoplasticsubclonescan bias the cytogeneticresults.This is a majorreasonwhy the use of establishedcell lines can have seriousdisadvantages.Pronouncedselection may occur among clones that were presentalready in vivo and chromosomalaberrationsthat emergein vitro may be mistakenfor in vivo changes.Finally,manyhumantumorcell lines are known to be contaminatedby other human or animal cells (Lacroix, 2008). Direct preparations or short-termculturesarethereforeusually preferredfor cytogeneticanalysis.

CHROMOSOME BANDING In somaticcells, chromosomesaretypicallystudiedat the metaphasestageof the cell cycle when the chromatinis highly condensedand the chromosomemorphologyis well defined. In most bandingmethods,individualchromosomesareidentifiedby theirrelativesize, the positionof the centromere,and the patternsof transversestriations.Based on this, the short (p) and long (4) chromosomearmsaredividedinto differentmorphologicalregions, which in turn can be subdivided into bands and subbands, their number depending on the resolutionof the preparationtechnique. The first of these methods to be invented was Q-handing (Casperssonet al.. 1970), for which metaphasechromosomesare stainedwith quinacrinemustardandexaminedthrougha fluorescencemicroscope.A partialexplanation of the Q-bandingpatternis thatquinacrinestainsAT-richsequencesbrighterthanGC-rich sequences (Weisblumand De Haseth, 1972). Most strikingare the very bright Q-bands containinghighly AT-rich satellite DNA, particularlyon the distal part of the Y chromosome. G-handing (Fig. 2. I a) is obtained when the chromosomesare pretreatedwith a salt solution or a proteolyticenzyme before staining with Giemsa or equivalent stains. G-bandingyields approximatelythe same informationas Q-banding;bandsthat fluoresce intensely by Q-bandingstain darklyby G-banding.R-banding is obtainedby pretreatment with hot alkali and subsequentstaining with Giemsa or acridineorange (Dutrillauxand Lejeune,197I ). As the nameindicates,R-bandingyields a patternthatis the reverseof that obtainedby G- and Q-banding.However, since R-bandingstains the chromosomeends intensely,this techniquemay be preferableto G- or Q-bandingwhen it comes to detecting terminalchromosomerearrangements. Besides these whole-genome banding methods, there are several sequence-specific techniques.C-banding is producedby denaturingthechromosomespriorto Giemsastaining

11

CHROMOSOME BANDING

(a)

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-1 J

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.

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.

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FIGURE2.1 Examplesof differentcytogenetic techniquesapplied to the same case. A supernumerarynng chromosome(arrow)is identifiedby G-banding(a) in a mesenchymaltumorand shown by multicolor FISH (b) to contain sequences from chromosomes 9 (arrowhead)and 12 (arrow). Whole-chromosomepainting(c) of chromosomes9 (red) and 12 (green) corroboratesthese findings and multicolor chromosome 12 banding with yeast artificial chromosome probes (d) shows that sequencesfrom the MDM2(yellow) andCDK4 (violet)genes in 12q14-1 5 areamplifiedin the rings. Furtheranalysis by bacterial artificial chromosome arrayCGH (e) defines the boundariesof the CDKI and M D M 2 amplified segments; the y-axis correspondsto logz intensity ratios. lmages are courtesy of N. Mandahl and M. Heidenblad. (See the color version of this figure in Color Plates scction.)

12

CYTOGENETIC METHODS

TABLE 2.1

Comparison of Cytogenetic Methodologies

ChromosomeMetaphaselnterphase Multicolor Metaphase Array Banding FISH FISH Karyotyping CGH CGH > 1-5Mb > 50 kb > Mb

Approximateresolution level Cell culturerequired + Preselectedprobes required Direct link to sequence map Intercellularheterogeneity + detected Type of aberrations detected balancedrearrangements + aneuploidy + structurdimbalances allelic imbalances -

+

+ +

-

+

+I-b

+

+

+ + + -

+ + + -

+

"Orderof magnitudeof maximal functionalresolutionaccordingto Coe et al. (2007). 'Single-copy probesaretypicallydefinedon physicalgenomemapsbutpaintingprobesandsatelliteprobesare not. rRequiressingle-cell preparation. dPossible if SNPs are included in the array.

(Sumner,1972). The methodlabels the constitutiveheterochromatinand this particularly demarcatesthe variableheterochromatic blockson chromosomesI , 9, 16, andY. T-banding is a modificationof R-banding,stainingpredominantlythe terminalpartsof the chromosomes, whereasNOR-bandingis a procedurewhich utilizesa silverstainthatpreferentially accumulatesin the nucleolarorganizingregions, that is, the satellite stalk regions of the acrocentricchromosomes.Except for C-banding,which has the strengththatit efficiently and reliably stains several types of polymorphicsatellite DNA sequences,the sequencespecific banding methods today have mostly been replaced by in situ hybridization techniques. In contrast,G-bandingand other whole-genome banding methods are still used in routinecytogeneticdiagnosticinvestigationsand in correspondingresearch.Infact, chromosomebandingremainsthe only low-cost genome screeningtechniqueallowing the identificationof balanced as well as unbalancedgenomic rearrangementsin single cells (Table 2.1).

IN SITU HYBRIDIZATION In situ hybridizationtechniquesare based on the inherentorganizationof DNA into two antiparallelcomplementarystrands.Afterdenaturation of targetDNA in metaphasespreads or interphasenuclei, single-strandedDNA probes are allowed to form hybrid doublestrandedcomplexes with theircomplementarygenomic sequences.Before hybridization, probescan be labeledby fluorophoresto allow directdetectionby fluorescencemicroscopy (Pinkel et al., 1986; Cremeret al., 1988). This fluorescencein situ hybridization(FISH) strategyallows simultaneousdetectionof severalgenomicsequencetargetsas fluorophores of different wavelengths can be combined in the same hybridizationexperiment and

COMPARATIVE GENOMIC HYBRIDIZATION

13

concurrentlydetected (Fig. 2.1b-d). However, probes can also be labeled with nonfluorescenthaptens, allowing secondarydetection by enzymatic methods analogous to those used in immunohistochemistry.This chromogenic in situ hybridization(CISH) techniqueavoidsthe problemof tissueautofluorescenceand can thereforebe advantageous fordirectanalysisof fixed tissuesections(Tanneret al., 2000;Hsi et al., 2002). However,the numberof colors availablefor chromogenicdetectionis still quite limited. One great advantageof FISH is its versatilitywith respect to targetsequences.Whole chromosomesorlargepartsof thechromosomescanbe targetedbypaintingprobes, whereas centromeres,telomeres,NOR regions,andpolymorphicsatellitescan be detectedby specific repeat sequence probes. Furthermore, single-copy probes can be manufactured by amplificationof genomic DNA cloned into librariesof variousvectors such as cosmids, fosmids, bacterialartificialchromosomes(BACs), and yeast artificialchromosomes(YACs).These probescan targetuniquesequencesdown to the gene level. Single-copyprobesare highly useful to map chromosomebreakpointsin metaphasepreparationsor to searchfor copy numberchanges in metaphaseor interphasecells. All these FISH applicationsrequire preexperimental selectionof which sequencesto examine;one only gets informationabout those sequencesone probesfor.Differentiallabelingof severalprobesmay circumventthis problemandthusmakewhole-genomescreeningby FISHpossible.Inmulticolor karyotyping,simultaneoushybridizationof differentlylabeledpaintingprobesallows chromosome identificationby assigningeachpairofhomologouschromosomes acertainspectralsignature (Schrkketal.,1996;Speicheretal., 1996;Tankeetal.,1999).Thisapplicationis particularly useful forresolvingthe compositionof complexstructuralaberrationsbutmay havelimited resolutionwhen very small chromosomefragmentsareinvolved (Lee et al., 200 I). Similar combinatoriallabelingof single-copyprobescan also be used to createcolor bundzng along thelengthof one orseveralchromosomes.Someof thesemethodsarebasedon cross-species hybridizationor microdissectionof chromosomesegments(Miilleret al., 1998; Chudoba et al., 2004), whereasothersarebasedon smallersequencesthatcan be tracedbackdirectly to the humangenome sequence map (Lengaueret al., 1993;Gisselssonet al., 2000).

COMPARATIVE GENOMIC HYBRIDIZATION Comparativegenomic hybridization(CGH) is an efficient method for the detection of genomic segments that are overrepresentedor underrepresented in a neoplastic sample. DNA is firstextractedfromthe tumorspecimenanda normalreferencesample,respectively, differentiallylabeled with Auorophores,mixed, and allowed to hybridizecompetitivelyto complementarytargetsequences(Kallioniemiet al., 1992).Originally,the targetsequences were normalchromosomespreads(chromosomalormetaphaseCGH)wherethe ratioof test to reference fluorescence along the chromosomes was quantifiedusing digital image analysis. This approachhas now largely been replacedby defined DNA fragmentsfixed in a matrixsystem (arrayCGH),providingmuch higherresolutionthan metaphaseCGH. Currentlyavailable array CGH platforms are either based on relatively large human sequencescloned into bacterialartificialchromosomelibraries(BAC arrays)or based on shortersingle-strandedoligonucleotides(oligonucleotidearrays),which may or may not include single-nucleotidepolymorphisms(SNP arrays).Apartfrom efficiently detecting gains and losses of genome sequences, S N P arrayscan be employed to assess genomic imbalancesnot reflected as copy numberabnormalities,such as loss of heterozygosity (LOH)by uniparentaldisomy (Bignell et al., 2004; Zhao et al., 2004).

14

CYTOGENETIC METHODS

The resolutionof DNA arraysprimarilydependson theirunderlyingdesign concept,for example,thetotalnumberof DNA targetsequences,theirindividuallengths,andthedistance between them (Aradhyaand Cherry,2007). Even within a specific array platform,the resolutionis oftendifferentfordifferentpartsof thegenome.Furthermore, the resolutionfor an individualtumorsampledependson uniqueexperimentalconditionssuchas thedegreeof contaminationby DNA from non-neoplastictissues, which often makes the practical resolutionof arrayCGHlowerthanexpectedfromtheoreticalcalculations(Coeet al.,2007). Anotherdisadvantageof thearrayCGHmethodologyis thatit reflectsa theoreticalaverageof a tumorsampleso that intercellularvariabilityis difficultto assess. Techniqueshave been establishedfor unbiasedPCR amplificationof small amountsof DNA, for instancefrom microdissectedtumorsamples(Speicheret al., 1993, 1995; Wiltshireet al., 1995) or from single cells (Klein et al., 1999; Wells et al., 1999). This has made it possible to compare genomic profiles fromdifferentpartsof a single tumor.A remainingdisadvantageof array CGH techniquesthat waits to be resolved is their failure to detect balanced inversions, insertions,and translocations.Nevertheless,the typically high resolutionof arrayCGH methodologies,theirpotentialfor roboticstreamlining,andthe fact thatthey do not require living cells for analysishave quickly madethem ubiquitoustools in cancercytogenetics.

INTERPRETATION OF CYTOGENETIC DATA Eventhoughthe technicalpossibilitiesto detectgenomicrearrangements in neoplasmshave increasedtremendouslyin recentyears,severalprincipalissues regardingthe interpretation of cytogeneticdataremainunresolved.One exampleis the findingof a normalkaryotypein a neoplasticsample(Pandiset al., 1994). In many cases, particularlywhen the cells were culturedpriorto analysis,this couldbe explainedby the presenceof non-neoplasticcells in the sample. Anotherexplanationis thatthe studiedcells truly belonged to the neoplastic parenchymabut that theirpathogeneticmutationswere below the resolutionlevel of the method used for analysis. Even with high-resolutionFISH or arrayCGH, mutationsin single genes will most probably be missed and may require targeted sequencing for detection.Finally, the possibility remainsthat no mutationwas present in the neoplastic cells, leavingthe alternativesthatpathogeneticabnormalitiesexist at the epigeneticlevel or that tumorigenesiscan also occur via completely nongeneticmechanisms. Another question is whether all abnormalitiesfound upon analysis of a seemingly representativesample are actually significant.Consideringthe high resolutionof novel array-basedtechniquesand the high degreeof polymorphicvariationin the humangenome, both at the single nucleotideandat the copy numberlevel, it is of greatimportanceto define which submicroscopicchangesare of pathogeneticimportanceand which are a partof the normal spectrumof interindividualgenome variation(Rodriguez-Revengaet al., 2007). Furthermore,very little is still known about submicroscopicgenome variation among differenttissues fromthe same individual.It is importantto rememberthatacquiredclonal chromosomechanges have also been found in some lesions that are classified as nonneoplasticby morphologicaland clinical criteria(Ray et al., I99 I ;Johanssonet al., 1993; Broberget al., 1999).Interpretation of the massiveamountof genomicdatageneratedby the novel high-resolutionscreeningtechniqueswill have to rely on systematiccomparisonof tumorsampleswithcontroltissues,ontheone hand,anddatabasesofnormalhumansequence variationon the other hand. Undoubtedly,publicly availableresourcesfor such in silico cytogeneticswill become increasinglyimportantfor tomorrow’stumorcytogeneticists.

REFERENCES

15

AradhyaS, CherryAM (2007): Array-basedcomparativegenomic hybridization:clinical contextsfor targetedand whole-genome designs. Genet Med 9:553-559. Bignell GR, HuangJ, GreshockJ, WattS, ButlerA, West S, GrigorovaM, Jones KW, Wei W, Stratton MR, FutrealPA, WeberB, ShaperoMH, WoosterR (2004): High-resolutionanalysis of DNA copy numberusing oligonucleotide microarrays.Genome Res 14:287-295. BrobergK, Hoglund M, Limon J, LindstrandA, Toksvig-LarsenS, Mandahl N, Mertens F (1999): Rearrangementof the neoplasia-associatedgene HMGICin synovia from patients with osteoarthritis. Genes Chromosomes Cuncer 24:278-282. CasperssonT, Zech L, JohanssonC (1 970): Differentialbindingof alkylatingfluorochromesin human chromosomes. Exp Cell Res 60:315-3 19. ChudobaI, Hickmann G, Friedrich T, Jauch A, Kozlowski P, Senger G (2004): mBAND: a high resolution multicolor banding technique for the detection of complex intrachromosomalaberrations. Cytogenei Genome Res 104:39&393. Coe BP, Ylstra B, CarvalhoB, MeijerGA, MacaulayC, Lam WL (2007): Resolving the resolution of arrayCGH. Genomics 89547-653. CremerT, LichterP, BordenJ, WardDC, ManuelidisL (1988): Detection of chromosomeaberrations in metaphaseand interphasetumorcells by in situ hybridizationusing chromosome-specificlibrary probes. Hum Genet 80:235-246. DutrillauxB, LejeuneJ (197 I): Surune nouvelle techniqued’analysedu caryotypehumaine.CRAcad Sci Paris D 272:2638-2640. Gissclsson D, MandahlN, Pilsson E, GorunovaL, HoglundM (2000): Locus-specificmultifluorFISH analysis allows physical characterizationof complex chromosome abnormalities in neoplasia. Genes Chromosomes Cancer28:347-352. Hsi BL, Xiao S, Fletcher JA (2002): Chromogenic in situ hybridization and FISH in pathology. Methods Mol Biol204343-35 I . JohanssonB, Heim S, MandahlN, MertensF, Mitelman F (1993): Trisomy 7 in nonneoplasticcells. Genes Chromosomes Cuncer 6: 199-205. KallioniemiA, KallioniemiOP,SudarD,RutovitzD,GrayJW,WaldmanF,PinkelD(1992): Comparative genomic hybridizationfor molecularcytogenetic analysis of solid tumors.Science 258:8 1 8-82 1 . Klein CA, Schmidt-Kittler0,SchardtJA, PantelK, SpeicherMR, RiethmullerG (1999): Comparative genomic hybridization,loss of heterozygosity, and DNA sequence analysis of single cells Proc Nut1 Acad Sci USA 964494-4499. Lacroix M (2008): Persistent use of “false” cell lines. Int J Cuncer122: 1 4 . Lee C, Gisselsson D, fin C, NordgrenA, Ferguson DO, Blennow E, FletcherJA, MortonCC (2001): Limitations of chromosome classification by multicolor karyotyping. Am J Hum Genef 68: 1043-1047. LengauerC, SpeicherMR, PoppS, JauchA, TaniwakiM. NagarajaR, RiethmanHC, Donis-Keller H, D’Urso M, Schlessinger D, et al. (1993): Chromosomal bar codes produced by multicolor fluorescence in situ hybridizationwith multiple YAC clones and whole chromosome painting probes. Hum Mol Genet 2505-5 12. MullerS, 0’Brien PC, Ferguson-SmithMA, WienbergJ ( I 998): Cross-speciescolour segmenting: a novel tool in human karyotypeanalysis. Cytometry 33:445-452. PandisN, BardiG, Heim S (1994): Interrelationshipbetween methodologicalchoices andconceptual models in solid tumor cytogenetics. Cancer Genef Cvtogenet 76:77-84. Pinkel D, Straume T, Gray J W ( 1986): Cytogenetic analysis using quantitative, high-sensitivity, fluorescence hybridization.Proc Nut1 Acad Sci USA 83:2934-2938.

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CYTOGENETIC METHODS

Ray RA, MortonCC, Lipinski KK, CorsonJM, FletcherJA (1 991): Cytogeneticevidence of clonality in a case of pigmented villonodularsynovitis. Cancer 67: 121-125. Rodriguez-RevengaL, Mila M, Rosenberg C, Lamb A, Lee C Structuralvariation in the human genome: the impact of copy numbervariantson clinical diagnosis. Genet Med 9:2007 600-606 Schrkk E, du ManoirS, VeldmanT, Schoell B, WienbergJ. Ferguson-SmithMA, Ning Y,Ledbetter DH, Bar-Am I, Soenksen D, Garini Y, Ried T Multicolor spectral karyotyping of human chromosomes.Science 273: 1996 494497 Speicher MR, Carter NP (2005): The new cytogenetics: blurring the boundaries with molecular biology. Nat Rev Genet 6:782-792. SpeicherMR, du ManoirS, Schrock E, Holtgreve-GrezH, Schoell B, LengauerC, CremerT, Ried T ( 1993): Molecular cytogenetic analysis of formalin-fixed, paraffin-embeddedsolid tumors by comparative genomic hybridization after universal DNA-amplification. Hum Mol Genet 2 1907-1 914. Speicher MR, Jauch A, Walt H, du Manoir S, Ried T, Jochum W, Sulser T, Cremer T (1995): Correlation of microscopic phenotype with genotype in a formalin-fixed, paraffin-embedded testiculargerm cell tumorwith universalDNA amplification,comparativegenomic hybridization, and interphasecytogenetics. Am J Pathol 146:1332-1 340. SpeicherMR Gwyn BallardS, WardDC ( 1996): Karyotypinghumanchromosomesby combinatorial multi-fluorFISH. Nat Genet 12:368-375. SumnerAT ( 1972): A simple techniquefordemonstratingcentromericheterochromatin.ExpCell Res 75:304-306. Tanke HJ, WiegantJ, van Gijiswijk RP, Bezrookove V, PattenierH, HeetebrijRJ,TalmanEG, Raap AK. Vrolijk J (1999): New strategyfor multi-colourfluorescence in situ hybridisation:COBRA: CombinedBinary RAtio labelling. Eur J Hum Genet 7:2-1 I . TannerM, GancbergD, Di Leo A. LarsimontD, Rouas G, PiccartMJ, Isola J (2000): Chromogenicin situ hybridization:a practicalalternativefor fluorescencein situ hybridizationto detectHER-2heu oncogene amplification in archival breastcancer samples. Am J Patho/ 157: 1467-1 472. Tjio JH,Levan A (1956): The chromosome numberof man. Hereditas 42: 1-6. Weisblum B, De Haseth PL (1972) Quinacrine,a chromosome stain specific for deoxyadenylatedeoxythymidylaterich regions in DNA. Proc Natl Acad Sci USA 69:629632. Wells D, Sherlock JK, HandysideAH, Delhanty JD (1999): Detailed chromosomaland molecular genetic analysis of single cells by whole genome amplification and comparative genomic hybridisation.Nucleic Acids Res 27: 121 4-1 218. WiltshireRN, DurayP, BittnerML, VisakorpiT, Meltzer PS, TuthillRJ, LiottaLA, TrentJM (1995): Direct visualization of the clonal progression of primarycutaneous melanoma: applicationof tissue microdissection and comparativegenomic hybridization.Cancer Res 5539543957. ZhaoX , Li C, Paez JG, Chin K, JannePA. ChenTH,GirardL,MinnaJ, ChristianiD, Leo C, GrayJW, SelIersWR, Meyerson M (2004): An integratedview of copy numberand allelic alterationsin the cancer genome using single nucleotide polymorphism arrays. Cancer Res 64:306&307 1.

CHAPTER 3

Cytogenetic Nomenclature SVERRE HEIM and FELIX MITELMA N

Human chromosome nomenclature is based on a consensus reached at several international conferences, after each of which reportscontaining recommendations for a uniform system of karyotype description have been published. The most recent and authoritative document is "An Internationa l System for Human Cytogenetic Nomenclature (2005)," abbreviated ISCN (2005), and the reader is well advised to consult this text for detailed descriptions and definitions and as a daily working guide to how abnormal karyotypes should be interpreted and written. What follows is only a brief summary of the most essential cytogenetic terminology related to the description of chromosome aberrations in neoplastic cells. Chromosomes are classified according to their size, the location of the centromere (that separates the chromosome into two arms), and the banding pattern along each arm. The autosomes are numbered from 1 to 22 in descending order of length; the sex chromosomes are referred to as X and Y. A schematic illustration, an idiogram, of the normal human male karyotype is presented in Fig. 3.1.

DESIGNATION OF REGIONS AND BANDS Each chromosome arm—the short arm is called p, the long one q—may consist of one or more regions. Each region is delimited by specific landmarks, that is, consistent, distinct, morphologic features of importance in chromosome identification. Landmarks include the ends of chromosome arms (the telomeres), the centromere, and also certain characteristic bands. A region consists of one or more bands and is denned as the area thatlies between two adjacent landmarks. A band is denned as a chromosomal area that is distinguishable from adjacent segments by appearing darker or lighter with one or more banding techniques. Since the chromosomes are visualized as consisting of a continuous series of light and dark transverse bands, no "interbands " exist. Regions and bands are numbered consecutively from the centromere outward along each chromosome arm. Thus, the two regions adjacent to the centromere are number 1 in each arm; the next, more distal region is number 2, and so on. A band used as a landmark by

Cancer Cytogenetics, ThirdEdition, edited by Sverre Heim and Felix Mitelman Copyright © 2009 John Wiley & Sons, Inc.

17

18

CYTOGENETICNOMENCLATURE

1

6

2

3

7

8

4

9

10

5

11

12

f# ' 13

14

16

15

20

17

18

rG

2:

19

2l

21

22

X

Y

FIGURE 3.1 Schematic presentation (idiogram) of the G-banded human male chromosome complement.

definition belongs entirely to the region distal to the landmark, and hence constitutes band number 1 of that region. In designating any particular band, four items are therefore required: the chromosome number, the arm symbol, the region number, and the band number within that region. These

KARYOTYPICNOMENCLATURE

19

items are given in consecutiveorderwithout spacing or punctuation.For example, 9q34 means chromosome9, the long a m , region 3, band4. The mitotic process is characterizedby increasing chromosomalcontraction,and chromosomes in prometaphaseor early metaphase are therefore more elongated than midmetaphasechromosomes.The bandingpatternof these earliermitoticphases is more complex,as severalof the conventional,midmetaphasebandsaresplitinto subbands.Thus, with high resolutionor fine structurebanding,smallerdetailsof chromosomemorphology may be visualized.Whenevera midmetaphaseband is subdivided,a decimalpointfollowed by the numberassignedto each subbandis placed afterthe originalbanddesignation.Like the midmetaphasebands, the subbandsare numberedconsecutively from the centromere outward.For example, the original band lq42 may be subdivided into three subbands, labeled lq42.1, lq42.2, and 1q42.3. If subbandsare subdivided,additionaldigits, but no furtherpunctuation,are used. Forexample,subbandlq42. I may be furthersubdividedinto lq42.11, 1q42.12, and so on.

KARYOTYPIC NOMENCLATURE In the karyotypedescription,the first item to be recordedis the total numberof chromosomes, followed by a comma (J. The sex chromosomeconstitutionis given next. Thus, a normalfemale karyotypeis written46,XX, the normalmale karyotype46,XY. To specify structurallyalteredchromosomes,single- and three-letteredabbreviations (given subsequently)areused. Thenumberof the chromosomeor chromosomesinvolvedin the rearrangementis specified within parenthesesimmediately following the symbol indicatingthe type of rearrangement. If two or morechromosomesarealtered.a semicolon (;) is used to separatetheir designations.If one of the rearrangedchromosomesis a sex chromosome,this is listed first;otherwise,the ruleis thatthe lowest chromosomenumberis mentionedfirst.The breakpoints,given within parentheses,are specifiedin the sameorder as thechromosomesinvolved,andsemicolonis againused to separatethebreakpoints.Note that punctuationis never used in intrachromosomalrearrangements,that is, to separate breakpointsin the same chromosome. The termsused to describeabnormalkaryotypesaredefinedby the ISCN (2005). Below are given some of the more common abbreviationsand examples of how they are used: Translocation,abbreviatedt: This meansthata chromosomalsegmentmoves fromone chromosometo another(Fig. 3.2). The translocationmay or may not be reciprocal.46,XX, t(9;22)(q34;ql I ) thus describes an otherwise normal female karyotype containing a translocationbetween chromosomes9 and 22 with the breakpointin chromosome9 at bandq34 and in chromosome22 at bandq l 1. Similarly,t(3;9;22)(q13;q34;qlI ) indicatesa three-breakrearrangement involvingbandq 13 in chromosome3, bandq34 in chromosome 9, and band ql 1 in chromosome22. Insertion, abbreviatedins: This means that a chromosomalsegment moves to a new, interstitialposition in the same or anotherchromosome.The chromosomein which the segmentis insertedis always specifiedfirst.Forexample,ins(5;2)(p14;q22q32)meansthat breakageand reunionhave occurredat band 5pl4 in the shortarmof chromosome5 and bands2q22 and 2q32 in the long arm of chromosome2. The segmentfrom 2q22 to 2q32 has been inserted into 5p at band 5 ~ 1 4 The . designation ins(2)(q13p13p23)describes an insertionof the segmentbetweenbands2p 13 and2p23 into the long arm of chromosome 2 at 2q13.

20

CYTOGENETICNOMENCLATURE

9

22

t(9;22)(q34;qll)

FIGURE 3.2 Translocation, illustrated as t(9;22)(q34;q 1 I).

Inversion, abbreviatedinv: Thisdesignatesa rotation180" of a chromosomesegment.In the karyotype46,XY,inv(16)(p13q22),breakageandreunionhaveoccurredat bands 1 6 ~ 1 3 and 36q22. The segment between these bandsis still presentbut upside down (Fig. 3.3). Deletion, abbreviateddel: This means loss of a chromosomal segment (Fig. 3.4). Whethera deletionis interpretedas terminalor interstitialis apparentfrom the breakpoint designations.Thus, del( I)(q23) indicatesa terminaldeletion with the breakat band lq23 and loss of the distal long arm segment.The remainingchromosomeconsists of the entire shortarm of chromosomeI andthe partof the long arm thatis betweenthe centromereand band lq23. In contrast,del(I)(q21q31) indicatesan interstitialdeletionwith breakageand reunionat bands lq21 and lq31. Duplication,abbreviateddup:This indicatesthe presence of an extracopy of partof a chromosome(Fig. 3.5). The breakpointsdelineatethe duplicatedsegment,for example, dup(1)(q21q31). fsochromosome,abbreviatedi: Isochromosomesconsist of armsthatare mirrorimages of one another.They resultfrom misdivisionof the centromere(transversebreakage).One example is i( 12p), an isochromosomefor the shortarm of chromosome12 (Fig. 3.6). The designationi( 12p)may be used in text,butthe isochromosomeshouldbe writteni( I2)(p10)

16

inv(l6Mpl3q22)

FIGURE 3.3 Inversion, illustrated as inv( I6)(p13q22).

KARYOTYPIC NOMENCLATURE

1

21

del(1 Nq21q31)

FIGURE 3.4 Deletions may be terminal or interstitial. The terminal deletion del( l)(q23) is illustrated to the left, the interstitial delf 1 )(q2I q3 I) to the right.

in karyotype descriptions.The “band” 1 2 ~ 1 0is a fictitious one; it is the side of the midcentromericplanethatfaces towardthe shortarm.An isochromosomefor the long arm of chromosome12 would have been writteni(12)(qIO). Ring chromosome,abbreviatedr : The essentialfeatureof a ringchromosomeis evident from the name. Breakshave occurredin both the shortand the long armswith subsequent fusion to form a ring structure,for example, r(6)(p21q24).

1

dup(l)(q21qW

FIGURE 3.5 Duplication, illustrated as dup( l)(q2 lq3 I).

22

CYTOGENETIC NOMENCLATURE

12 i(12)(p10) FIGURE 3.6 Isochromosome formation, illustrated as i(l2)(pl0). Marker chromosomes, abbreviated mar. This is used to signify any structurall y rearranged chromosome. When the banding pattern is recognizable, however, the marker can be adequately described by the standard nomenclature,and so the term is better avoided for these situations. The precise current definition of a mar is a structurall y abnormal chromosome in which no part can be identified. When additionalmaterial of unknownorigin is attached to a chromosome region or band, this may be described by the term add before the breakpoint designation. For example, add( 19)(p 13) indicates that extra material has become attached to t is band 19pl3, but neither the origin of the added segment nor the type of rearrangemen known. Such abnormalities have often been described using the symbols t and ?, for example, t(19;?)(p!3;?), but since it is only rarely known that the rearrange d chromosome actually results from a translocation, the use of the symbol add is recommended. Derivative chromosomes, abbreviated der. This means not only any structurall y rearranged chromosome generated by an abnormality involving two or more chromosomes but also the structura l rearrangement s generated by more than one aberration within a single chromosome. The term der always refers to the chromosome(s) that has an intact centromere. s involved The derivative chromosome is specified in parentheses, followed by all aberration in the generation of the derivative chromosome. For example, der(l)t(l;3)(p32;q21)t(l; l I) (q25;ql3) specifies a derivative chromosome 1 generated by two translocations, one involving the short arm with a breakpoint in 1 p32 and the other involving the long arm with a breakpoint in lq25. Homogeneouslystaining regions and double minute chromosomes,cytogenetic signs of gene amplification, are abbreviated hsr and dmin, respectively. Plus (4-) and minus (—) signs are placed before a chromosome number to indicate an additional or missing whole chromosome. They are placed after a symbol to indicate an increase or decrease in the length of a chromosomal arm. Thus, 47,XY, + 21 means a male karyotypewith 47 chromosomes, including an additional chromosome 21, whereas 2 lq + indicates an increase in the length of the long arm of one chromosome 21. The latter terminology should be restricted to written text; in formal descriptions of karyotypes, a 21q + should be described using the add symbol, that is, add(21)(q?).

REFERENCES

23

NOMENCLATURE OF TUMOR CELL POPULATIONS A clone is defined as a cell populationderived from a single progenitor.It is common practiceto infer a clonal origin when a numberof cells have the same or closely related abnormalchromosome complements. A clone is therefore not necessarily completely homogeneous, neither karyotypically nor phenotypically, since subclones may have evolved duringthe developmentof the tumor. An internationallyacceptedoperationaldefinition(ISCN, 199I , 2005) says thata clone exists if two or more cells are found with the same structuralaberrationor supernumerary chromosome.If the abnormalityis a missing chromosome,the samechangemustbe present in at least three mitoses. The general rule in tumor cytogenetics is that only clonal chromosomalabnormalitiesshould be reportedin the tumorkaryotype. The stemline indicatesthe most basic clone in a tumorcell population.All additional deviatingclonal findingsare termedsidelines. When more than one clone is present,the Such multipleclones karyotypedesignationsof each clone are separatedby a slant line (0. may be cytogeneticallyrelatedor unrelated. The modalnumber is the most commonchromosomenumberin a tumorcell population. The modal numbermay be describedas near-diploid when it is approximatelydiploidbut without a sharpmode. The modal numberis hypodiploid when the mode is less than 46 chromosomes,and hyperdiploid when it is more than 46. Modal numbersin tumorcell populationsmay also be describedas haploid,triploid,tetraploid,hypotriploid,near-triploid, hypertriploid,hypotetraploid,near-tetraploid,hypertetraploid, and so on, dependingon the predominantchromosomenumber.Karyotypeswith a normal chromosomenumberbut that nevertheless contain numerical and/or structuralaberrations,may be described as pseudodiploid.

IN SITU HYBRIDIZATIONNOMENCLATURE The in&uction of variousin situ hybridizationtechnologiesinto the cytogeneticanalysis of interphaseand metaphasecells has led the InternationalStandingCommitteeon Human CytogeneticNomenclatureto proposean in situ hybridization(ish)nomenclaturesystem thatmay be used to describeabnormalitiesat the molecularlevel by indicating,forexample, the presence,absence,amplification,or separationof specific probesignals.The majoraim of this ish nomenclatureis to enable investigatorsto evaluateat a glance in a shorthand system how an individualchromosomalabnormalityhas been identifiedand characterized. The informationobtainedby in situ hybridizationstudiesor othertechniquesused to study chromosomeaberrations,for example,comparativegenomichybridization,can always be transcribedinto a karyotypedescriptionusing the establishedcytogenetic nomenclature system. For a descriptionof the special symbols and abbreviationsused to reporthow ish resultsare obtained,the readershould consult ISCN (2005).

REFERENCES ISCN ( 1 99 1 ): Guidelinesfor Cancer Cytogenetics: Supplement to un IntermtionulSystemfor Human Cytogenetic Nomencluture. Mitelman F, editor. Basel: S. Karger. ISCN (2005): An Internationul System for Human Cytogenetic Nomenclature. Shaffer LG, TommerupN, editors. Basel: S. Karger.

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CHAPTER4

Nonrandom Chromosome Abnormalities in Cancer-An Overview

SVERRE HElMand FELIXMITELMAN

The main conclusion to emerge from modem cancer cytogenetics is that the karyotypic changesof tumorcells are unevenlydistributedthroughoutthe genome. Differentchromosomes, regions, and bands are preferentially involved in rearrangementsin different neoplasms.Furthermore,a steadilyincreasingnumberof specific abnormalitiesare found to be associatedwith particulardiseases or disease subgroups,as is describedin detail in Chapters5-23. In this chapter,we discuss neoplastickaryotypesin more general terms; we shall emphasize the differencebetween primaryand secondarychanges, addressthe questions of why, how, when, and where chromosome abnormalitiesarise, compare numericalandstructuralaberrationsin termsof how they contributeto tumordevelopment, andalso touchupon the issues of whatcausescancer-associatedchromosomeabnormalities andwhetherthey arenecessaryand/orsufficientto transforma normalcell intoa cancercell. Some of the more principaldifferencesbetween the cytogenetic and moleculargenetic approachesto the studyof acquiredsomaticcell mutationswill also be discussed,beforewe endby dwellinga biton the relativevirtuesof pathogeneticversusphenotypicclassifications of tumors. At the very beginning,however,it may be worthwhileto get an overviewof the totalityof informationavailablefor assessment.Thecancercytogeneticsdatabaseis undergoingrapid changesas numerousreportsdescribingnew karyotypicabnormalitiesin humanneoplasia arecontinuouslybeing addedto the scientificliterature(Fig. 4. I 1. All publishedcytogenetic dataare systematicallyrecordedin the MitelmanDatabaseof ChromosomeAberrationsin Cancer(Mitelmanet al., 2008) thatcataloguesdetailedkaryotypicdescriptionsandclinical and morphologicalfeatures on all reportedneoplastic cases with a clonal cytogenetic abnormalityidentifiedby bandinganalysis. The databasealso containsinformationon the moleculargenetic consequencesand the prognosticimpactof acquiredcytogeneticand/or molecular genetic rearrangementsin neoplasia. The information is integratedinto the “CancerGenomeAnatomyProject”(CGAP)-an interdisciplinaryprogramwith the aim of the genes associated with carcinogenesisand to to create an informationinfrastructure develop technologicaltools to supportthe analysisof the molecularprofileof cancercells (Wheeleret al., 2005). The CGAPthusfacilitatesthe integrationof cytogenetic,mapping, Cuacrr Cytogemtics, Third Edition, edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

25

26

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCERAN OVERVIEW

1

i

i

50,000.

-

- -0 00,04 m

-c 0

0

-

5 30,000-

'5 m

d

20,000-~

-

10,000-

-

c

0

I,

0 1975

1980

1985

1990

1995

2000

2005

Year

FIGURE 4.1 Overview of the cancer cytogenetics database as it has evolved since the first descriptionsof acquiredchromosomeaberrationsidentifiedby bandingtechniquesin the early 1970s.

and sequence data pertainingto cancer diseases from a variety of sources. Recently, multicolorfluorescencein situ hybridization(M-FISH) and comparativegenomichybridization (CGH) databaseshave also been incorporated(Knutsen et al., 2005) into this searchableplatform. At the time of writing,clonal chromosomeaberrationshave been identifiedin morethan 55,000 neoplasms,includingmalignanthematologicdisorders,malignantlymphomas,and benign and malignantsolid tumors.This is undoubtedlyan impressivefigure,and it might perhapsbe temptingto conclude that sufficient data must now be at hand to deductall informationon cancerbiology thatmay be gainedthroughcytogeneticanalysis.However,a closerlookatthematerialrevealsthatformanyimportanttumortypes(e.g.,carcinomasof the uterinecervix,prostate,andskin),theknowledgeis actuallyextremelylimited.Ingeneral,the leukemiasare by far the most thoroughlyinvestigated.Of the presenttotal, hematologic disorderscomprise58%, lymphomas15%, andsolid tumorsmakeup theremaining27%of the cases. The number of cytogenetically characterizedsolid tumors is hence totally to the relativeimpactof thesediseaseson humanmorbidityandmortality. disproportionate One mighteven say thatan inverserelationshipexists between the numberof studiedcases andtheirclinicalimportance.The leukemiasandmalignantlymphomasmakeup 73%of all cases but cause only 10% of humancancer deaths, whereasthe majorcancer killer, the malignantepithelialtumorsresponsiblefor 90%of cancermortality,is representedby only 10%of thecasesinthedatabase.Infact,we knowless aboutthecytogeneticsof all carcinomas today than we did aboutone leukemiasubtype,acute myeloid leukemia,20 years ago. Inaddition,therearetechnicalandanalyticalproblemsthatlimittheinformationvalue of the existing cytogenetic data on malignant epithelial tumors. First, the chromosome morphologyis often poor, or at least inferiorto that in leukemiasand lymphomas,which means that many of the publishedcases have been only partiallykaryotyped.Second, investigationsof carcinomashave often been performedlate in thedisease,on samplesfrom effusionsor metastases,thatis, at a timewhen the karyotypemay be dominatedby complex secondarykaryotypicchanges (see below) accruedduringtumorprogression.A further

PRIMARYAND SECONDARY NEOPLASIA-ASSOCIATEDCHROMOSOMEABNORMALITIES

27

challenge is the presenceof cytogeneticallyunrelatedclones, which are foundin less than 3% of leukemias,lymphomas,and mesenchymaltumorsbut have been reportedin up to 60% of various carcinomas (Jin et al., 2001). All these circumstancescompound the difficulties in pinpointingthe essential genomic rearrangementsin early tumor development. More cytogenetic data are thereforeparticularlybadly needed for epithelial neoplasms.However,also in the most extensively investigatedleukemias,new aberrationsand new clinico-cytogeneticcorrelationsare still being discovered,illustratingthe continuing necessity for cytogeneticresearcheven in those disordersfor which the databaseis most solid. It should also be noted thata substantialproportionof the cytogeneticallyabnormal leukemiaspublishedso farrepresentselectedcases reportedbecause they had a characteristic or unusualchromosomeabnormality(Mitelmanet al., 2005), giving a false impression of the actual frequencies of many recurrentcytogenetic aberrations.More data on consecutive series of unselectedpatientmaterialsare needed in orderto establishthe true prevalenceof all chromosomeabnormalitiesalso in leukemiasand lymphomas.

PRIMARY AND SECONDARY NEOPLASIA-ASSOCIATED CHROMOSOME ABNORMALITIES Numerousspecificchromosomalabnormalitieshavebeen detectedin almostall tumortypes that have been examined,and the remainderof this book containsdetaileddiscussionsof these cytogenetic-pathologicrelationshipsand the molecularconsequencesof the aberrations whenever such knowledge is available.In spite of the unquestionablekaryotypic nonrandomness,the main impression gained from a cursory examinationof the total databaseis its enormous heterogeneity.Practicallyall kinds of abnormalitieshave been reported,only the frequenciesand the clinico-morphologiccontexts vary. More often than not, several changes are present simultaneously.One is compelled to ask the following questions: are all the aberrationspathogeneticallyimportant,are only some aberrations important,or-in principleequallypossible4oes none of them reflect essentialevents in the neoplastic transformationof initially normal cells? That the latter query must be answeredin thenegativehasnow been establishedbeyonddoubt,inasmuchas the molecular consequences of several rearrangements(activation of oncogenes or inactivation of suppressorgenes) have been clarifiedandshownto be causallyimportantin the tumorigenic process (Chapters5-23). The best approximationto biologicalrealitymay be achievedby subdividingthe various clonal aberrationsinto those that are primaryand those that are secondary(Heim and Mitelman,1989).The acquisitionof microscopicallyvisible mutationsby the tumorcells is, like tumorigenesisitself, in most instancesa multistageprocess. Primary aberrations are frequentlyfound as the sole karyotypicabnormalitiesin cancerand are often specifically associatedwithparticulartumortypes.Thetermprimarynot only refersto the factthatthese are the first changes we see in neoplastic cells, but also reflects their causal role in tumorigenesis;they are essential in establishingthe neoplasm. In principle, of course, what we detect firstneed not necessarilybe the firstmutation,andone has to be open to the possibility that submicroscopicmutation(s) may in given instancesprecede the primary chromosomalabnormality(see also below). The issue remainsunresolved,but at least it seems fair to say that a broad consensus has evolved that the tumor-specificprimary chromosomeabnormalitiesoccurin the earlieststagesof carcinogenesis,thatthey represent rate-limitingsteps, and that they indeed are a conditio sine qua non for the whole process.

28

NONRANDOM CHROMOSOME ABNORMALlTlES IN CANCER-AN OVERVIEW

Secondaryaberrations,on the contrary,are rarelyor never found alone; as the name implies,theydevelopin cells alreadycarryinga primaryabnormality.In laterdiseasestages, however, they may be so numerousas to completely dominatethe karyotypicpicture. Although less specific than primarychanges, secondaryaberrationsneverthelessdemonstratenonrandomfeatureswith distributionpatternsthat appearto be dependentboth on which primaryabnormalityis present and on the type of neoplasm. This is presumably achieved in the following manner(Nowell, 1976, 1986; Heim et al., 1988; Heim, 1993): chance disturbancesof the mitotic process, in some cases presumablyfacilitatedby a mutatorphenotype effect of the primaryabnormality,provide a randombackgroundof genetic variability in the tumor.The genetically rearrangedcells that thus emerge are immediatelyand continuouslytested for “evolutionaryfitness” in a Darwinianmanner, with proliferativelysuperiorsubclonesgraduallyexpandingat the expenseof less fit cells. Dependingon how the selectionpressurechanges, typicallywhen infiltratingor metastatic cells findthemselvesin a new localeoraftercytostatictreatmentis instituted,the totaltumor karyotypemay evolve towardgreateror less complexity (genetic divergenceand convergence, respectively). We emphasize that this evolutionary scenario is not principally dependenton whetherthe neoplasticprocess startsout as monoclonal(as implied above) or begins with the more or less simultaneoustransformationof many cells. If the latter, polyclonalpathwayis the one followed by some neoplasms-and cytogeneticdataon many carcinomasindicatethat this may be the case-then oligo- or monoclonalitymay develop secondarily, for example, after the basal lamina is penetratedand the tumor begins to infiltrate(Heim et al., 1988; Heim, 1993). The operational division between primary and secondary acquired chromosome aberrationsoutlinedabove has also been proposedto reflect a deepergenetic, and hence most likely functional,distinction (Johanssonet al., 1996) in that primaryaberrations consist of specific gene rearrangements, whereassecondarychromosomalchangesresult in large-scale genomic imbalances. According to this hypothesis, then, there are no unbalancedprimaryaberrations,only secondary imbalancesmasqueradingas primary. This proposition, if correct, has a number of conceptual ramifications (Johansson et al., 1996). First, the genetic mechanismsunderlyingtumorinitiationand progression would seem to be totally different.Second,the elucidationof the molecularconsequences of the secondaryaberrationswill be an arduoustask, even if one were to adhereto the, in our opinion overly simplistic, view that cytogenetically identified genomic imbalances may be reducedto simple gains or losses of single oncogenes or tumorsuppressorgenes (TSG). Third,the cytogeneticdiagnosis of neoplasmswill have to take into accountthat unbalanced “primary” abnormalitiesare secondary to submicroscopic,truly primary changesof majordiagnosticand prognosticimportance.Whetherthe suggestedscheme is correctaboutsubmicroscopicmutationsalways precedingchromosomalones is possible, butcurrentlynot provable.Whatis an observablefact is thatsecondarychangesnot always bring about large-scalechromosomalimbalances. For example, the Burkittlymphoma/ leukemia-specific8;14-translocation(Chapter 10) sometimes occurs secondarilyin follicular non-Hodgkinlymphomaswith t( 14;IS) as the primaryabnormality(Gauwerky et al., 1988), which then alter their clinical behaviorcorrespondingly,and if an inv(l6) occurs during clonal evolution of chronic myeloid leukemia (CML) with the primary 9;22-translocation,an acute myelomonocytic leukemia results (Chapter5 ; Heim et al., 1992).Sometimesprimarychromosomerearrangements may occursecondarily,evidently, and it would be surprisingif the opposite were not also the case, albeit possibly on rare occasions only.

WHY AND HOW DO CHROMOSOMEABERRATIONSARISE?

29

FIGURE 4.2 Metaphase from a cancer cell showing extreme karyotypic complexity. Among the massive numerical as well as structural chromosome abnormalities were also many that represented cytogenetic noise, changes that were found in this cell only.

In additionto the evolutionarilyimportantprimaryand secondarychromosomeaberrations that by definitionmust be found in clonal proportions,not only extremecytogenetic complexity (Fig. 4.2) but also variabilitywith no two identical cells is sometimes seen, especiallyin solid tumors.The termcytogeneticnoise has been used for theseextensivebut nonclonal abnormalities(Heim and Mitelman,1989).

WHY AND HOW DO CHROMOSOME ABERRATIONS ARISE? Are primaryand secondarychromosomeabnormalitiesalwaystheresultof chanceevents? Are they only, as the secondarychanges were depictedabove, the productsof stochastic alterationsoccurringmore or less continuouslythroughoutthe genome, with selection for proliferativeadvantagedeterminingwhich ones will give rise to tumorsand,hence, can be detected?This is a thoroughlylogical, simple, and attractivepossibility,and it is probably the hypothesis shared by the majorityof researchersin the field. However, a different scenariocannot be ruled out: certaingenomic rearrangements, perhapsespecially those which frequentlyoccur as primaryabnormalities,might be preferentiallyinduced, for example,throughdirectinteractionbetweena carcinogenicagentandspecificgenomicsites in the target cells. It has been convincingly shown that many external genotoxic agents inducechromosomalbreaks(Obe et al., 2002). and epidemiologicalstudies have shown an association between the extent of chromosomaldamage and cancer risk (Bonassi et al., 2005). Some early evidence fromcytogeneticinvestigationsof experimentaltumors also supportsthe view that more or less specific chromosomalaberrationpatternsmay be

30

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCER-AN OVERVIEW

dependenton theinducingagent(Mitelmanet al., 1972;Mitelman,1981). Thisproposition has also been substantiatedin some human malignanciesassociated with occupational, environmental,andorgenotoxicexposures(Mitelmanet al., 1978;Mauritzsonet al., 2002; Pedersen-Bjergaard et al., 2002), and severalagentshave been shown to increasethe risk of particulartranslocations/genefusions, deletionsas well as numericalabnormalities,for example, DNA topoisomerase11 inhibitors(Zhangand Rowley, 2006), alkylatingagents (Escobaret al., 2007), agriculturalpesticides (Chiu et al., 2006). benzene (Smith et al., 1998), and radiation(Rabes et al., 2000). An importanttopic in this context is the observationof geographicheterogeneityof cancerchromosomeabnormalities.It has long been known thatcancerfrequenciesdiffer bothgeographicallyandamongethnicgroups.Datahavealso come forthindicatingthatthe aberrationpatternsof apparentlyidentical malignancies may vary significantlyamong laboratoriesfromdifferentpartsof the world (Johanssonet al., 1991;Segel et al., 1998;Lee et al., 2002; Remsteinet al., 2006). Partlythis probablyreflects differentascertainment practicesdueto suchfactorsas variablereferralroutinesanddifferencesin age composition amongthe patientsinvestigated.Thechoice of technicalprocedures,includingwhich media are used and whetherdirectpreparationsor short-termculturesare relied upon (Jin et al., 1993; Pandis et al., 1994), may also be important.However, for several abnormalities explanationsalong these lines seem insufficient to account for the observedvariability. Population differences in the response to carcinogens,possibly reflecting polymorphic variabilityin DNA repaircapacity,couldperhapsexplainsome of thegeographicvariations. Anotherexplanation,however,mightbe thatspecificetiologic factorsdirectlyor indirectly induce or influence the nonrandomaberrationpatterns. In additionto externalagents,host factorsmight also have a rolein the originof specific chromosomeaberrations.One importanthost factoris chromosomeinstability.Thereare many inheritedcancer-predisposingdisorders, including the well-known chromosome breakagesyndromesassociated with instability at the chromosomaland/orDNA level (Taylor,2001; Eyfjordand Bodvarsdottir,2005) and an increasedincidenceof translocations involving some chromosomalregions more thanothers(Aplan, 2006). Forexample, patientswith ataxia-telangiectasia,causedby mutationof theATMgene ( I 1q22) thatplays an importantrole in the recognitionand repairof DNA double-strandbreaks,are prone to develop translocationsinvolving the T-cell or immunoglobulinantigen-receptorloci (Rotmanand Shiloh, 1998). Also patientswith the Nijmegen breakagesyndrome,caused by a mutationin the NBN gene (8q21) that, like ATM, is involved in the repairof DNA double-strandbreaks, frequentlydisplay translocationsaffecting immunoglobulinand T-cell receptorgenes (Digweed and Sperling,2004). Anothercause of chromosomeinstability is telomere dysfunction(Gisselsson, 2005), which throughbreakage-fusion-bridge cycles maycausenumericalas well as structuralchromosomeaberrations(Murname,2006). Thus, it seems clear thatinheritedor acquiredgenomic instabilitygeneratedby increased formation of DNA breaks and/or failure of cell cycle checkpoints may facilitate the appearanceof chromosome aberrationsand predisposeindividualsto develop various cancers. It stands to reason that the three-dimensionalchromosome architecturewithin the interphasenucleus, the organizationof the genetic material into relatively well-defined spatial intranucleardomains (Misteli, 2005; Cremeret al., 2006), in some way must influence the likelihood with which various structuralchromosome aberrationsarise. ProbablyDNA double-strandbreaks are requiredfor most, if not all, such aberrations. Therefore,at least some degree of physical proximitybetween breakpointregions seem

IN WHICH CELLS W CHROMOSOME ABERRATIONS ARISE?

31

essential for the formationof any chromosomerearrangement.In fact, several loci recombinedin specifictranslocations-BCWABLI in chronicmyeloid leukemia(Chapter7), PMURARAin acute promyelocyticleukemia(Chapter5), RET/CCDC6 in thyroidcancer (ChapterI8), andIGH/MYC, IGH/CCNDZ, andIGH/BCL2 in B-cell malignancies(Chapter 10)-have been found to be close to each other in the correspondingnormal cell types (referencesin Mitelman et al., 2007). However, in view of the fact that almost 10,000 recurrentbalanced aberrationsinvolving every chromosome band have been reported (Mitelmanet al., 2008). we deem it unlikelythatthe interphasepositionof the breakpoints involved is sufficient to explain the origin of all rearrangements.Another factor that might facilitate illegitimate recombinationin a major way is sharedsequence motifs at the chromosomebreakpoints(Aplan,2006; Povirk,2006;ZhangandRowley, 2006). Future sequencingefforts will no doubt shed light on this importantissue, includingthe relative contributionof chance to what might appearas specific aberrationinduction,as will also additionalstudies of the interphasenuclearanatomyof susceptibletargetcells. We see, therefore,thatmanyof the “whys” and “hows” interact,thedistinctionbetween themis sometimesblurredandanythingbuteasy,andthe mainmechanismsarenot mutually exclusive.Takentogether,however,thereis little evidencefavoringany substantialimpact of specific externalor internalfactors on the genesis of nonrandomchromosomeabnormalities. For the time being and at our present level of understandingof the processes involved, we are compelled to believe that most of the primaryand secondary cancerassociatedcytogenetic aberrationsarise as stochasticevents.

WHEN DO CHROMOSOME ABERRATIONS ARISE? It is quiteclear thattumorswith chromosomeabnormalitiesmay be diagnosedat any age. Structuraland numericalaberrationshave been recordedin newbornsand patientsup to the age of 100 years (Mitelmanet al., 2008). When the aberrationsarise, however,is a moot point. For childhood hematologic malignanciesthere is ample evidence, based on twin studiesand polymerasechain reaction(PCR)analysesof specific gene fusions in Guthrie spots, that they may be formed already in utero, several years prior to overt leukemia (Greavesand Wiemels,2003). To whatextent leukemiasin adultshave a clonal originthat can be traced many years back, perhapseven to early childhoodor prenatallife, is not known, For solid tumors,lack of appropriatepreneoplastictissue samplescollected before diagnosishasprecludedsimilarinvestigations.It would undoubtedlybe of greatinterest,for example,in cancerepidemiologicalstudies,to identifymoreexactly when in life translocations and gene fusions arise in differentcell types. It is difficult to envisage how such informationcould possibly be obtained,however; perhaps,as stated by Boveri already in 1914, it will never be possible to study a tumor “in statu nascendi.”

IN WHICH CELLS DO CHROMOSOME ABERRATIONS ARISE? Cancer stem cells have attracted much attention. It is now generally accepted that hematologicmalignanciesare sustainedby leukemicstem cells, capableof both initiating andmaintainingthe disease.Morerecently,the cancerstem cell concepthas been shownto be applicablealso to some malignantsolid tumors,for example,of the breast,colon, lung, and centralnervoussystem (Huntlyand Gilliland,2005; Wang and Dick, 2005: Ailles and

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NONRANDOMCHROMOSOME ABNORMALITIES IN CANCER-AN OVERVIEW

Weissman,2007; Sales et al., 2007). A fundamentalquestion is whetherthe neoplasiainducingprimarychromosomeabnormalitiesarise in normal stem cells or whetherthey occur at a later stage in differentiation.A paradigmaticexample of a translocationoriginatingin a stem cell is the t(9;22) giving rise to the Philadelphiachromosomein chronic myeloid leukemia,as demonstratedalreadyin the early 1960s (referencesin Johansson et a]., 2002). Also a few othergene fusionshave been shown to be present inthe stemcell compartmentor in early progenitorsin acute leukemias (Castoret al., 2005; Hotfilder et al., 2005; Hong et al., 2008), but most leukemia-associatedgene fusions have not been subjectedto this type of investigation.In solid tumors,such studiesaredifficultto perform becauseso little is knownaboutthe differentiationhierarchyin the tissues fromwhich they derive.Recentdataindicate,however,thatbone marrow-derivedmesenchymalprogenitor cells may be involvedin sarcomadevelopment(Riggi et al., 2005,2006). It is undoubtedly going to be an arduoustaskto design and carryout experimentscapableof identifyingand characterizingthe targetcells, but only then will it be possible to understandwhy some chromosomeaberrations,including gene fusions resultingfrom structuralchromosomal rearrangements, such as EW6INTRK3, occurin a varietyof morphologicallyandclinically distinctneoplasms(LannonandSorensen,2005), whereasmost othersseem to be restricted to very specific cell and tumortypes.

ARE ACQUIRED CHROMOSOME ABERRATIONS SUFFICIENT FOR NEOPLASTIC PROLIFERATION? Severallines of evidence stronglyindicatethatthe answerto this questionis negative.The most compelling argumentis that many similar aberrationshave been found in nonneoplasticcells of healthy individuals.For example, trisomy 7 may be seen as the only changenot only in both benign and malignantsolid tumorsbut also in severalunquestionably non-neoplasticdisease lesions (e.g., osteoarthritis,Dupuytren'scontracture,andfocal steatosisof the liver) andeven in apparentlynormaltissues of, for example,brain,kidney, and lung (Johanssonet al., 1993; Broberg et al., 2001). Several typical leukemia- and lymphoma-associatedstructuralrearrangements have also been detectedin normalcells by both chromosomebandingand molecularmeans,in particularusing sensitivePCR assays (Basecke et al., 2002; Janz et al., 2003). Among the gene fusions identified in healthy individualsare RUNXURUNXI TI correspondingto t(8;21)(q22;q22),BCWABLI correspondingto t(9;22)(q34;qll),Eir7/6/RUNXI correspondingto t( 12;2l)(p13;q22),andlGH/ BCL2 correspondingto t( 14;1 8)(q32;q21). Cells carryingleukemia-associatedgene fusions may occasionallybe detectableseveralyearsaftersuccessfultreatment,for example,when the patientsarein long-termcompleteremissionandthereis little riskof relapse(Nucifora et al., 1993;Jurlanderet al., 1996).Long anddisparatelatencyperiodsbeforeovertleukemia in twins bornwith the same gene fusion,transmittedin utero, have been well documented (Greavesand Wiemels, 2003). Finally, there is circumstantialas well as direct evidence from murine leukemia models that additionalevents are a prerequisitefor malignant transformation(Kelly and Gilliland,2002). Thus, besides the necessity thatthe leukemogenic or carcinogeniceventstakeplace in suitablyprimed,susceptiblecells, somethingwe do not knowto be the case in thestudiesdemonstratinglow-level presenceof leukemogenic gene productsin healthy individuals,the availabledataindicatethat secondarychanges, most likely mutations,arenecessary,at leastin the contextof hematologicmalignancies.In contrast,there is some evidence that the expressionof certain sarcoma-associatedgene

DO ALL TUMORS HAVE CHROMOSOME ABNORMALITIES

33

fusions is sufficientfor transformationof bone marrow-derivedmesenchymalprogenitor cells in mice (Riggi et al., 2005, 2006). Whetherthe same holds true also for other solid tumors,includinggene fusion-drivencarcinogenesisin humans,remainsto be clarified,and so does the spectrumof mutated genes associated with different gene fusions in both hematologicand solid neoplasms.It is clearthatourconceptualmodels of the pathogenetic impact of chromosome abnormalitiesneed to take into account the surprisinglylarge numberof other, submicroscopicsomatic mutationsrecently identifiedin human malignancies(Sjoblomet al., 2006; Greenmanet al., 2007; Wood et al., 2007); we still do not alwaysknow whatis signalandwhatis noise in thevast amountof suchdatanow being made available.

DO ALL TUMORS HAVE CHROMOSOME ABNORMALITIES, AND ARE SUCH CHANGES PRESENT ONLY IN NEOPLASTIC CELLS? A negativeanswerto the firstquestionseems obvious,since examplesaboundof tumorsin which only normalmetaphaseswere found. It shouldbe made absolutelyclear, however, thatthis in no way runscounterto the predictionsof the somaticmutationtheoryof cancer. The haploidhumangenome containsroughly3 x lo9 base pairs (bp) and since structural rearrangementsinvolving chromosomal segments much smaller than a band are not detected with present-daycytogenetic techniques,it follows that genetic changes of as much as 106-107 bp may occurwithoutvisible alterationof chromosomalmorphology.So even if the somaticmutationtheory were to show 100%concordancewith reality,some of the acquiredmutationswould be expected to be too small to be seen microscopically.As recentlyshown in cancerof the prostate(Tomlinset al., 2005; Kumar-Sinhaet al., 2006), lung (Rikova et al., 2007; Soda et al., 2007; Campbellet al., 2008), and breast (Ruan et al., 2007), gene fusionsdo occur in importanttumortypes with the breakpointsso close to each other or involving so similar-loolungchromosomalsegmentsthat theirdetection had to awaitthe introductionof methodologiesotherthanchromosomebanding,including genome-wideexpressionand sequencinganalyses. An additional but partly related problem is that one cannot be certain whether cytogenetically normal cells isolated from tumor samples really are part of the tumor parenchyma.In the absenceof any informationaboutpossible submicroscopicaberrations in these cells, is it not more likely thatthey in most instancesbelong to one of the stromal componentsubiquitousto every tumor?Bandinganalysisalone evidentlycannotprovidea conclusiveanswer.Combinedanalysesof thecells’genotypeandphenotype,somethingthat has provednotoriouslydifficultto obtain,could providemorereliableknowledgeaboutthis problem,and might also be expected to shed light on what at first glance seems to be the diametricallyopposite issue, namely the ontologic and pathogeneticstatusof the cytogeneticallyunrelatedclones thatare found so often in many solid epithelialtumors(see, for example,Chapters13 and 15). It is not clearwhetherthesecells, which typicallycarryonly relativelysimple aberrations,belong to the tumorparenchyma(in which case one has to considerseriouslythe possibilityof polyclonal carcinogenesis),or whetherthey are nonneoplastic.A qualitygradingof the chromosomalaberrations(simple or complex?)based on cytogenetic impressionsalone is not always sufficient;many examples are known of balanced,solitary chromosomalrearrangementsthat have a most profoundtumorigenic impact(Mitelmanet al., 2007). The questionhasmajorimplicationsforourreasoningabout the pathogenesisof cancerousas well as other hyperproliferativedisease processes and

34

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCER-AN OVERVIEW

should, sooner ratherthan later, be addressedby means of appropriatecombinationsof cytogenetic and other techniques.

GENERAL EFFECTS OF STRUCTURAL AND NUMERICAL CHROMOSOME ABNORMALITIES Two mainclasses of cancer-relevantgenes, the oncogenesandthe tumorsuppressorgenes, have been recognized as main pathogenetic targets for cancer-associatedkaryotypic abnormalities,andnumerousexamplesof oncogene activationandsuppressorgene inactivationaregiven in the furtherchapters.Herewe shallonly outlinein very schematicfashion may have. the principalgeneticeffects thatdifferenttypes of chromosomalrearrangements Either they lead to loss of genetic material,gain of material,or balancedrelocation of chromosomalsegments(Fig. 4.3).

Net Loss of Chromosomal Material This may be caused by deletions, unbalancedtranslocations,or loss of entire chromosomes (monosomy). Standardpathogenetictheory holds that such changes are carcinogenic by removingtumorsuppressorgenes. However,there are now several examplesof fusion genes thathave been producedby juxtapositionof partsof two genes delineating, most often, cryptic deletions, for example, STZmALl in acute lymphoblasticleukemia,

Loss of genetic material

Gain of genetic material

Relocation of genetic material

1 -[1 1 1 -I1 1 I -1 I

Inversion

Insertion

Translocation

FIGURE 4.3 The chromosome aberrationsof cancer may in principle exert their effect through gain or loss of genetic material or through structural or regulatory changes brought about by relocation of chromosomal segments.

GENERAL EFFECTS OF STRUCTURALAND NUMERICALCHROMOSOME ABNORMALITIES

35

M W A R H G E F l 2 , MLUCBL, and MLLJTIRAP in acute myeloid leukemia, FIPILU PDGFRA in hypereosinophilicsyndrome,HAS2/PLAG/ in lipoblastoma,and TMPRSS2/ ERG in prostatecancer (referencesin Mitelmanet al., 2007). It will be exciting to learn how often gene fusions turnout to be the importantoutcome of the many deletions that have been described not only cytogenetically but also increasinglyby array-basedanalyses of genomic imbalances (Cowell and Nowak, 2003; Pinkel and Albertson, 2005; Speicher and Carter, 2005). It also remains to be established what role is played by epigenetic gene silencing which is now more and more being appreciatedas an alternative to mutations and deletions to disruptTSG function in cancer cells (Clark, 2007; Gronbaeket al., 2007; Miremadiet al., 2007). Finally, even when deletions work by loss of TSG, we do not know how consistently this loss of function adheres to the two-hit model of Knudson(1971). Some recent evidence from, for example, the del(5q) of acute myeloid leukemia and myelodysplasia(Chapters5 and 6) indicatesthat loss of a single allele (haploinsufficiency)may be sufficient for the defect to make itself felt phenotypically (Joslin et al., 2007; Ebert et al., 2008).

Net Gain of Chromosomal Material Malsegregationmay give rise to trisomy or more extensive polysomies. Duplicationand triplicationof particularchromosomalregionsor segmentsmay also lead to an unbalanced gene product. In all cases, a simple dose effect could conceivably be the mechanism wherebythe extraDNA is influential,for example,by addingone or more active oncogene alleles. It should be stressed that this explanationis still entirely speculative, however. Severalstudieshave shownthatthe expressionof a considerablefractionof genes locatedin regions of gains or losses of chromosomal material varies consistently with DNA copy number,butnot all genes affectedby copy numberchangesshow an alteredexpression.For example, in a studyof acutemyeloid leukemia(Schochet al., 2006), gain of chromosome8 was found to lead to a higher expression of genes located on chromosome 8, but no consistent patternof overexpressedgenes was identified that would have allowed a clear discriminationof trisomy8 cases fromthose with a normalkaryotype.Also, as discussedin Chapter13, Platzeret al. (2002) and Cardosoet al. (2007) found that the great majorityof genes located in areas of chromosome amplificationin colorectal cancer did not show upregulationof expression.

Relocation of Sequences with No Gain or Loss of Genetic Material Rearrangementsleading to this result may be interchromosomal(translocationsand insertions) or intrachromosomal(inversions). By recombining DNA sequences in this manner, genes may be destroyed, new fusion genes may be created, or the regulatory control of genes may be interferedwith. Such position effects are the mechanismbehind the chromosomal activation of oncogenes in several human neoplasms (Mitelman et al., 2007), and numerous examples to this effect will be presented in the following chapters. We also need now be cognizant of the fact that even in what seems cytogenetically to be balanced rearrangements,cryptic deletions or duplications in the breakpointregion(s) may occur (Sinclair et al., 2000; Kolomietz et al., 2001). A mixture and blurring of the boundaries between the three major mechanisms by which cytogenetic alterationsexert their effects may thereforebe more common than was initially appreciated.

36

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCER-AN

OVERVIEW

AT WHAT RESOLUTION LEVEL ARE NEOPLASIA-ASSOCIATED MUTATIONS BEST STUDIED? The genetic profileof tumorscan be assessed at many differentlevels of resolution,all of which depend on the utilization of particularmethodologies that each has its own developmentalhistory, advantages,and disadvantages.The techniques include classic cytology, whereby the size, shape, and staining characteristicsof individualnuclei are determined;flow cytometry,which gives informationaboutthe total DNA contentof the averagetumorcell; cytogenetics,the maintopic of thisbook; andmoleculargeneticstudies at the level of genes or primaryDNA structure. It is the latterapproachthatin the last two decadeshas commandedthe greatestinterest, both in the scientificcommunityand among the generalpublic. At times the focus on the moleculargenetics of cancerhas been so strongthat all other and older means of gaining relevantinformationseem to have been forgotten;surely,the fascinationwith new things andtoys is one of the most profoundcharactertraitsin man.If it were so thatthe molecular genetic approachreally helped answerall relevant questionsabout the acquiredgenetic changes of neoplasticcells betterthan can be done by, say, cytogeneticanalysis,then the total and unconditionalembracingof the new shouldnot be lamentedbutwelcomed. If, on the contrary,the suspicionarisesthatimportantaspectsof cancergeneticsareneglectedby a one-sided recombinant DNA strategy, then one should try to readdressour current approachesto see if they really are optimally suited to what is the common goal of all cancergeneticists:to achievethe best possible understandingof the genetic processesthat drive tumorigenesis.A clear appreciationof the ontological, methodological,and epistemological relationshipbetween the cytogeneticsand moleculargenetics of tumorcells is vital to obtainingsuch a balancedattitude.We here want to emphasizeonly some of the factors that play a role. A fuller discussionof the topic may be found in Heim (1992). Onthe face of it, the one importantdifferencebetweenthe cytogeneticandDNA levels is thatthe objectsunderinvestigationdifferin size. Point mutations,small deletions,and any other rearrangements involving stretchesof DNA smallerthan the minimumrequiredfor microscopicdetectioncannotbe evaluatedby morphologicmethodsbutmay be studiedby chemicaltechniques,by the methodsof moleculargenetics.Thatsuchsmallchangesmay be functionallyimportantis beyondquestion;hence, in this regardthe moleculargeneticsof cancer is obviously superiorto cytogeneticinvestigations. The chemical natureof recombinantDNA techniquesand their enormousresolution power also lead to some inherentlimitations, however, which sometimes tend to be overlooked when the genomic changes of tumors are discussed only from a molecular perspective.Firstand foremost,mostmoleculargeneticmethodsaredependenton probing with DNA sequencesthathybridizespecifically at given sites. No informationis obtained about those areas that are not probed, no matterhow massive rearrangements they may contain.Bandinganalysis, on the contrary,is a screeningmethod that poses nonspecific, open-framequestions.All thatcan be seen cytogeneticallyis seen, withintheboundariesset by the resolutionachievedin thatparticularmitoticcell; themethodis not dependenton any ability to “guess right” when the investigation is planned.In the last few years, some technologicalbreakthroughs havebeen madethatpromiseto bridgetheepistemologicalgap betweenthe molecularmethodswith theirinherentspecificityandthe screeningqualitiesof karyotypingtechniques.Array-basedtechniquesnot only can detect copy numberimbalances whenever these are present, but can also identify chromosomal breakpoints with unprecedentedprecision.New sequencingmethods,amongthempaired-endmapping

PATHOGENETICVERSUS PHENOTYPICTUMOR CLASSIFICATION

37

(Ng et al., 2005; Korbel et al., 2007), offer unique possibilities to screen for balanced rearrangementsin a novel manner.The technology has alreadybeen applied to cancer studiesandhas led to theidentificationof previouslyunknownfusiongenes in breast,colon, andlungcancer(Ruanet al., 2007; Campbellet al., 2008); it is a fascinatingnew approachto look for cancer-associatedrearrangements in an unbiased,genome-wide fashion. Whereasmoleculargenetic analysesof a cancerbegin with the isolationof DNA froma smalleror largertumorsample, cytogenetic studies requirethat live, individualcells are removedfrom the tumorparenchyma.Although one could envisage procedureswhereby single tumorcells are isolated,the DNA from each of them extractedseparately,and the materialsubsequentlysubjectedto analysisby PCRorothertechniquesthatmay be capable of yielding informativeresultswith such minuteamountsof DNA as that stemmingfrom single cells, this has not yet been demonstratedto be a practicableapproach.In normal moleculargenetic practice,the DNA is obtainedfrom all cell types within the sample,be they stromalor truly neoplastic, and after the extractionthere is no way to differentiate between the materialderivingfrom the differentsources.The subsequentanalysis therefore yields a picture of an idealized, average tumorcell that not only may incorporate featuresof nontumorouscomponents,but thatwill also fail to reveal genomic differences among differentsubsetsof tumorparenchymacells. The resultis an inherentbias toward homogeneity;whateverheterogeneitytheremight havebeen amongclones or subclonesof neoplastic cells remainsundetected. It is our conviction that analyses should proceed from the large to the small, that one shouldscrutinizethe detailsonly afterone has a good idea as to which of them arelikely to be the most important.Likewise, the searchfor informationaboutever smallerentities of pathogeneticimportance-be they isolatedat the genic or DNA primarystructurelevelshouldbe accompaniedby parallelandno less consistentsyntheticefforts,by attemptsto see how the new data fit the knowledge obtainedat higher levels of complexity. In short, cytogeneticand moleculargeneticinvestigationsof neoplasticcells must be balanced,they must operatein concert.Only then can the partlyoverlapping,partly uniqueinformation yielded by the two approachesbe synthesizedinto a pictureof carcinogenesisthatis at the same time both profoundin understandingand comprehensivein scope.

PATHOGENETIC VERSUS PHENOTYPIC TUMOR CLASSIFICATION In all the remainingchaptersof this book, chromosomalaberrationpatternsare being correlatedwith diagnoses. Sometimesremarkableconcordancebetween the pathological diagnosis and one cytogenetic or moleculargenetic rearrangementor a given aberration patternwill be noted, sometimesa nonrandomrelationshipwill be pointedout but not one thatis completely specific, but on otheroccasions no clear-cutcytogenetic-pathologic or cytogenetic-clinical relationshipcan be discerned. How are we to make sense of this variability,if the acquiredchromosomalaberrationsare pathogeneticallyessential? Currentclassificationof neoplasiasoccurs accordingto several mostly morphological schemes- gross anatomical,histological, and cytological-to which modifying information from other fields, often immunology,may be added.Pathogeneticconsiderations traditionallyplay no or only a negligible role in the diagnosticgroupingof cancers,and as long as the therapeuticmeasures are not specifically directed against the molecular mechanismsthathave gone awry, thereis not much impetusfor this to change;adequate surgicalremoval of a macroscopictumor is not dependenton an understandingof what

38

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCER-AN OVERVIEW

made the tumorgrow. Once treatmenttargetsthe moleculardefects of the cells making up the neoplastic parenchyma,however, accuratepathogeneticclassification,including cytogenetic classification,becomes essential. This was first seen for CML (Chapter7). Formerlyit was acceptedthat some CMLcases did not have t(9;22) or the corresponding gene fusion, BCWABLl, just as it was accepted that some cases of polycytheda Vera and otherchronicmyeloproliferativedisordersdid. The introductionof imatinibmesylate (Druker,2004), a drug that specifically counteractsthe abnormaltyrosine kinase activity of the protein product of the fusion gene, served as a great stimulus to trim the borderlinesof the disease category:cases displayingthe BCWABLI fusion were accepted as CML even if some phenotypic features were at odds with the usual mode of presentation,whereas cases without this genotypic markerwere now referredto other diagnoses. The increasedunderstandingof leukemogenesis,especially,butalso carcinogenesisand other types of tumorigenesisresultingfrom cytogenetic and otherstudies in the last few decadeshas paved the way for the introductionof manynew biologicallyactivedrugs that targetspecifically the defining moleculardetails of differentneoplastic processes. Once many such drugsbecome available,and this is going to happen in the next few years, it becomesadamantto determinewhetherany given tumorhasthe geneticfeaturein question, that is, a pathogenetic(cytogenetic,genomic) tumorclassificationwill be of the essence. Eventually,the goal is that the increasedpathogeneticknowledge will be translatedinto specificandefficienttherapiestailor-madeto each individualcancercase. Thetreatmentcan then become both rational and individualized,the latter term now meaning that it is specifically directed against the genetic individuality of the cancer cells as well as administeredin a manner that is best adaptedto the genetic individualityof the host organism,the patient.

ACKNOWLEDGMENT The long-term financial support of the Norwegian and Swedish Cancer Societies is gratefullyacknowledged.

REFERENCES Ailles LE, Weissman IL (2007):Cancer stem cells in solid tumors. Curr Opin Biorechnol18:460-466. Aplan PD (2006): Causes of oncogenic chromosomal translocation. Trends Genet 22:46-55. Basecke J, Griesinger F, Triimper L, Brittinger G (2002): Leukemia- and lymphoma-associated genetic aberrations in healthy individuals.Ann Hemalol81:64-75. Bonassi S, Ugolini D, Kirsch-Volders M, Stromberg U, Vermeulen R, Tucker JD (2005): Human population studies with cytogenetic biomarkcrs: review of the literature and future prospectives. Environ Mol Mutagen 45258-270. Boveri T (1914): Zur Frage a’er Entsiehung maligner Tumoren. Jena, Germany: Gustav Fischer. Broberg K, Toksvig-Larsen S, Lindstrand A, Mertens F (2001):Trisomy 7 accumulates with age in solid tumors and non-neoplastic synovia. Genes Chromosomes Cancer 30:3 10-315. Campbell PJ, Stephens PJ, Pleasance ED, O’Meara S, Li H, Santarius T,Stebbings LA, Leroy C, Edkins S, Hardy C, Teague JW,Menzies A, Goodhead J, Turner DJ, Clee CM, Quail MA, Cox A, Brown C. Durbin R, Hurles ME, Edwards PAW, Bignell GR, Stratton MR, Futreal PA (2008):

REFERENCES

39

Identificationof somatically acquiredrearrangementsin cancer using genome-wide massively parallel paired-endsequencing.Nat Genet 40:722-729. CardosoJ, BoerJ, MorreauH, FoddeR (2007): Expressionandgenomicprofilingof colorectalcancer. Biochim Biophys Acta Rev Cancer 1775:103-137. I, BuitenhuisM, RamirezC, AndersonK, StrombeckB, CastorA. Nilsson L, Astrand-Grundstrom Garwicz S, BCkhssy AN, Schmiegelow K, Lausen B, Hokland P, Lehmann S, Juliusson G, JohanssonB, Jacobsen SE (2005): Distinct patternsof hematopoieticstem cell involvement in acute lymphoblasticleukemia.Nat Med 1 13630-637. Chiu BC, Dave BJ, BlairA, GapsturSM. ZahmSH, WeisenburgerDD (2006): Agriculturalpesticide use and risk of t( 14;18)-definedsubtypesof non-Hodgkinlymphoma.Blood 108:1363-1369. Clark SJ (2007): Action at a distance: epigenetic silencing of Large chromosomalregions in carcinogenesis.Hum Mol Genet 16Spec No I R88495. Cowell JK, Nowak NJ (2003): High-resolutionanalysis of genetic events in cancer cells using bacterialartificialchromosomearraysand comparativegenome hybridization.Adv Cancer Res 90~91-125. CremerT, CremerM, Dietzel S, Miiller S, Solovei I, Fakan S (2006): Chromosometemtories-a functionalnuclearlandscape.Curr Opin Cell Biol 18:307-3 16. Digweed M, Sperling K (2004): Nijmegen breakagesyndrome:clinical manifestationof defective responseto DNA double-strandbreaks.DNA Repair 3: 1207- 1217. DrukerBJ (2004): Imatinibas a paradigmof targetedtherapies.Adv Cancer Res 91 :1-30. EbertBL, PretzJ, Bosco I, ChangCY, TamayoP, Galili N, RazaA, Root DE, AttarE, Ellis SR, Golub TR (2008): Identificationof RPS14 as a 5q- syndromegene by RNA interferencescreen.Nature 45 I :335-339. chromosome EscobarPA, SmithMT, VasishtaA, HubbardAE,ZhangL (2007): Leukaemia-specific damagedetected by comet with fluorescence in situ hybridization(comet-FISH). Mulagenesis 22:321-327. EyfjordJE, BodvarsdottirSK (2005): Genomic instabilityandcancer:networksinvolved in response to DNA damage.Mutat Res 592:18-28. GauwerkyCE, Hoxie J, Nowell PC, Croce CM (1988): Pre-B-cell leukemia with a t(8;14) and a t( 14; 18) translocationis preceded by follicularlymphoma.Oncogene 2:431435. Gisselsson D (2005): Mitotic instability in cancer: is there method in the madness? Cell Cycle 4:1007- 1010. GreavesMF, Wiemels J (2003): Originsof chromosometranslocationsin childhoodleukaemia.Nut Rev Cancer 3:639-649. GreenmanC, StephensP, SmithR,DalglieshGL, HunterC, Bignell G, Davies H, TeagueJ, ButlerA, Stevens C, Edkins S, O'MearaS, Vastrik 1. Schmidt EE, Avis T, Barthorpe S , Bhamra G, Buck G, ChoudhuryB, ClementsJ. Cole J, Dicks E, Forbes S, Gray K, Halliday K, Harrison R, Hills K, HintonJ. JenkinsonA. JonesD, MenziesA, MironenkoT, PerryJ,RaineK,Richardson D, ShepherdR, SmallA, ToftsC, VarianJ, WebbT, West S , WidaaS , Yates A, Cahill DP,LouisDN, GoldstrawP,NicholsonAG, BrasseurF, LooijengaL, WeberBL, Chiew YE, DeFazioA, Greaves MF, GreenAR, CampbellP, BirneyE, EastonDF, Chenevix-TrenchG, TanMH, KhooSK, Teh BT, Yuen ST, Leung SY, Wooster R, FutrealPA, StrattonMR (2007): Patternsof somaticmutations in humancancergenomes. Nature 446:153-158. GronbaekK. HotherC, Jones PA (2007): Epigeneticchanges in cancer.APMIS 115:1039-1059. Heim S ( 1992): Is cytogeneticsreducibleto the moleculargenetics of cancercells? Genes Chromosomes Cancer 5:188-196. Heim S (I 993): Tumorprogression-karyotypic keys to multistagepathogenesis.In: lversen OH, editor.New Frontiers in Cancer Causafion: Exploring New Frontiers. Washington,DC: HemispherePublishingCorporation.pp 247-259.

40

NONRANDOM CHROMOSOME ABNORMALITIES IN CANCER-AN OVERVIEW

Heim S, MitelmanF (1 989): Primarychromosomeabnormalitiesin humanneoplasia.Adv Cancer Res 52: 1-44. Heim S, MandahlN, Mitelman F (1 988): Genetic convergenceand divergencein tumorprogression. Cancer Res 48591 1-5916. Heim S, Christensen BE, Fioretos T, Sarensen AG, Pedersen NT (1992): Acute rnyelomonocytic leukemiawith inv( 16)(p13q22) complicatingPhiladelphiachromosomepositive chronicmyeloid leukemia. Cancer Genet Cytogenet 59:35-38. Hong D, GuptaR, Ancliff P, AtzbergerA, BrownJ, Soneji S, GreenJ, ColmanS, Piacibello W, Buckle V, Tsuzuki S, GreavesM, EnverT (2008): Initiatingand cancer-propagatingcells in TEL-AMLI associated childhood leukemia. Science 319:336-339. HotfilderM, Rottgers S, Rosemann A, SchrauderA, SchrappeM, Pieters R, JurgensH, HarbottJ, VormoorJ (2005): Leukemic stem cells in childhoodhigh-riskALL/t(9;22) andt(4;1 1) arepresent in primitive lymphoid-restrictedCD34+CD19- cells. Cancer Res 65:1442- 1449. Huntly BJP, Gilliland DG (2005): Leukaemia stem cells and the evolution of cancer-stem-cell research.Nut Rev Cancer 5:311-321. JanzS , Potter M, RabkinCS (2003): Lymphoma-and leukemia-associatedchromosomaltranslocations in healthy individuals. Genes Chromosomes Cancer 36:2 11-223. Jin Y, MertensF, MandahlN, Heim S, Olegird C, WennerbergJ, BiorklundA, MitelmanF (I 993): Chromosomeabnormalitiesin eighty-threehead and neck squamouscell carcinomas:influenceof cultureconditions on karyotypicpattern.Cancer Res 53:2140-2146. Jin Y, MartinsC, SalemarkL, Persson B, Jin C, MirandaJ, Fonseca I, Jonsson N (2001): Nonrandom karyotypicfeaturesin basal cell carcinomasof the skin. Cancer Genet Cytogenet 131:109-119. Johansson B, Mertens F, Mitelman F ( 1991): Geographic heterogeneity of neoplasia-associated chromosomeaberrations.Genes Chromosomes Cancer 3: 1-7. JohanssonB, Heim S, MandahlN, MertensF, MitelmanF ( I 993): Trisomy 7 in nonneoplasticcells. Genes Chromosomes Cancer 6:199-205. Johansson B, MertensF, Mitelman F (1996): Primary vs. secondary neoplasia-associatedchromosomal abnormalities-balanced rearrangementsvs. genomic imbalances?Genes Chromosomes Cancer 16:155-163. JohanssonB, FioretosT,MitelmanF (2002): Cytogeneticand moleculargenetic evolutionof chronic myeloid leukemia. Acta Haematol 107:76-94. Joslin JM, FernaldAA, TennantTR,Davis EM, Kogan SC, AnastasiJ, CrispinoJD, Le Beau MM (2007): Haploinsufficiencyof EGR1, a candidategene in the del(5q), leads to the developmentof myeloid disorders. Blood 1 10:7 19-726. JurlanderJ,CaligiuriMA, RuutuT, BaerMR, StroutMP, OberkircherAR, HoffmannL, Ball ED, FreiLahrDA, ChristiansenNP,Block AM, KnuutilaS, Herzig GP, BloomfieldCD ( I 996):Persistence of theAMLIETO fusiontranscriptin patientstreatedwith allogeneic bone marrowtransplantation for t(8;21) leukemia. Blood 88:2 183-2 191. Kelly LM, Gilliland DG (2002): Genetics of myeloid leukemias. Amu Rev Genomics Hum Genet 3: 179- 198. KnudsonAG ( 1 971): Mutationandcancer:statisticalstudy ofretinoblastoma.Proc NatlAcadSci USA 68:820-823. KnutsenT, GobuV,KnausR,Padilla-NashH, AugustusM, StrausbergRL,KirschIR,SirotkinK, F5ed T (2005): The interactiveonline SKYN-FISH&CGH databaseand the Entrezcancer chromosomes search database:linkage of chromosomalaberrationswith the genome sequence. Genes Chromosomes Cancer 4452-64. KolomietzE, Al-MaghrabiJ, BrennanS, KaraskovaJ, Minkin S, LiptonJ, SquireJA (2001): Primary chromosomal rearrangementsof leukemia are frequently accompaniedby extensive submicroscopic deletions and may lead to altered prognosis. Blood 97:358 1-3588.

REFERENCES

41

KorbelJO, UrbanAE, AffourtitJP,Godwin B, GrubertF, Simons JF,Kim PM, PalejevD, Carrier0NJ. Du L, Taillon BE, ChenZ, TanzerA, SaundersAC, ChiJ, YangF, CarterNP,HurlesME,Weissman SM, Harkins 'YT, Gerstein MB, Egholm M, Snyder M (2007): Paired-end mapping reveals extensive structuralvariation in the human genome. Science 3 18:4201426. Kumar-SinhaC, TomlinsSA, ChinnaiyanAM (2006): Evidence of recurrentgene fusions in common epithelial tumors. Trends Mol Med 12:529-536. LannonCL, Sorensen PHB (2005): ETV6-NTRK3:a chimericproteintyrosine kinase with transformation activity in multiple cell lineages. Semin Cancer Biol 15:2 15-223. Lee DS, Kim SH, Seo El,ParkCJ,Chi HS, KOEK, Yoon BH, Kim WH, Cho HI (2002): Predominance of trisomy l q in myelodysplasticsyndromesin Korea:is thereanethnicdifference?A 3-year multicenter study. Cancer Genet Cytogenet 132:97-101. MauritzsonN, Albin M, Rylander L, Billstrom R, Ahlgren T, Mikoczy Z, Bjork J, StrombergU, Nilsson PG. Mitelman F, Hagmar L, Johansson B (2002): Pooled analysis of clinical and cytogenetic features in treatment-relatedand de novo adult acute myeloid leukemia and myelodysplastic syndromesbased on a consecutive series of 761 patients analyzed 1976-1993 and on 5098 unselected cases reported in the literature1974-2001. Leukemia 162366-2378. MiremadiA, OestergaardM Z , PharoahPD, Caldas C (2007): Cancergenetics of epigenetic genes. Hum Mol Genet 16:Spec No 1. R 2 8 4 4 9 . Misteli T (2005): Concepts in nuclear architecture.BioEssays 27:477-487. Mitelman F ( I98 1 ): Tumor etiology and chromosome pattern-vidence from human and experimental neoplasms. In: Arrighi FE. Rao PN, Stubblefield E, editors. Genes, Chromosomes. and Neoplasia. New York Raven Press. pp 335-350. MitelmanF, Mark J, Levan G, Levan A (1972): Tumoretiology and chromosomepattern.Science 176:1340-1341. Mitelman F, Brandt L, Nilsson PG (1978): Relation among occupational exposure to potential mutagenic/carcinogenic agents, clinical findings, and bone marrow chromosomes in acute noniymphocyticleukemia. Blood 5 2 1229-1 237. MitelmanF, Mertens F, JohanssonB (2005): Prevalenceestimates of recurrentbalancedcytogenetic aberrationsandgene fusions in unselectedpatientswith neoplasticdisorders.Genes Chromosomes Cancer 43:350-366. MitelmanF, JohanssonB, MertensF (2007): The impactof translocationsandgene fusions on cancer causation. Nal Rev Cancer 7~233-245. MitelmanF, JohanssonB, MertensF, editors(2008): Mitelman Databaseof ChromosomeAberrations in Cancer. Available at http://cgap.nci.nih.gov/Chromosomes/Mitelman. MumameJP (2006): Telomeres and chromosome instability.DMA Repair 5: LO82-1092. Ng P, Wei CL, Sung WK,Chiu KP, Lipovich L, Ang CC, GuptaS, ShahabA, Ridwan A. Wong CH, Liu ET, Ruan Y (2005): Gene identificationsignature(GIS) analysis for transcriptomecharacterization and genome annotation.Nut M e t h d 2: 105-1 I I. Nowell PC (1976): The clonal evolution of tumor cell populations. Acquired genetic lability permits stepwise selection of variant sublines and underlies tumor progression. Science 194:23-28. Nowell PC (1 986): Mechanismsof tumor progression. Cancer Res 46:2203-2207. NuciforaG , LarsonRA. Rowley JD ( 1993):Persistenceof the 8;21 translocationin patientswith acute myeioid leukemia type M2 in long-term remission. Blood 82:712-715. Obe G, Pfeiffer P, SavageJR,JohannesC, Goedecke W, JeppesenP, NatarajanAT, Martinez-L6pezW, Folle GA. Drets ME (2002):Chromosomalaberrations:formation,identificationanddistribution. Mutat Res 504: 17-36. PandisN, BardiG, Heim S (1994): Interrelationshipbetween methodologicalchoices andconceptual models in solid tumor cytogenetics. Cancer Genet Cytogenet 7677-84.

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Pedersen-BjergaardJ, Andersen MK, ChristiansenDH, Nerlov C (2002): Genetic pathways in therapy-relatedmyelodysplasiaand acute myeloid leukemia.Blood 99:1909-1912. Pinkel D, AlbertsonDG (2005): Arraycomparativegenomic hybridizationand its applicationsin cancer.Nut Genet 37:s 1 I S 17. PlatzerUpender MB,Wilson K, Willis J, LutterbaughJ, NorrattiA. Willson JKV, Mack D, Ried T, Markowitz S (2002): Silence of chromosomalamplificationsin colon cancer. Cancer Res 621134-1138. Povirk LF (2006): Biochemical mechanismsof chromosomaltranslocationsresulting from DNA double-strandbreaks.DNA Repair 5: 1199-1 2 12. R a k sHM,DemidchikEP, SidorowJD, LengfelderE, BeimfohrC, Hoelzel D, KlugbauerS (2000): in 191 post-Chemobylpapillary Patternof radiation-inducedRETand “I‘RKl rearrangements thyroid carcinomas: biological, phenotypic, and clinical implications. Clin Cancer Res 6 1093-1 103. RemsteinED, Dogan A, EinersonRR,PaternosterSF,FinkSR, LawM, DewaldGW, KurtinPJ(2006): The incidenceand anatomicsite specificityof chromosomaltranslocationsin primaryextranodal marginalzone B-cell lymphomaof mucosa-associatedlymphoidtissue (MALT lymphoma)in North America.Am J Surg Pathol30:1546-1553. Riggi N, CironiL, ProveroP, Suva ML, Kaloulis K, Garcia-EchevemaC, HoffmannF, TrumppA, StamenkovicI (2005): Development of Ewing’s sarcomafrom primarybone marrow-derived mesenchymalprogenitorcells. Cancer Res 65:11459-I 1468. Riggi N, Cironi L, ProveroP, Suva ML, Stehle JC, Baumer K, Guillou L, StamenkovicI (2006): Expressionof theFUS-CHOPfusionproteinin primarymesenchymalprogenitorcells gives riseto a model of myxoid liposarcoma.Cancer Res 66:7016-7023. RikovaK, Guo A, Zeng Q,PossematoA, Yu J, HaackH, NardoneJ, Lee K, Reeves C, Li Y, Hu Y, Tan Z, StokesM, SullivanL, MitchellJ, WetzelR, MacneillJ, Ren JM.YuanJ, BakalarskiCE, Villen J, KomhauserJM, Smith B, Li D, Zhou X,Gygi SP,Gu TL, PolakiewiczRD, Rush J, Comb MJ (2007): Global survey of phosphotyrosinesignaling identifiesoncogenic kinasesin lung cancer. Cell 13 1:1190-1 204. RotmanG. Shiloh Y (1998): ATM: from gene to function.Hum Mol Genef 7: 1555-1563. Rum Y, Ooi HS, Choo SW, Chiu KP, ZhaoXD, SrinivasanKG, Yao F, ChooCY, Liu J, AriyaratneP, Bin WG, KuznetsovVA, ShahabA, Sung WK, BourqueG, PalanisamyN, Wei CL (2007):Fusion transcriptsand transcribedretrotransposed loci discoveredthroughcomprehensivetranscriptome analysisusing Paired-EnddiTags (PETS).Genome Res 172328-838. Sales KM, Winslet MC, SeifalianAM (2007): Stem cells and cancer:an overview.Stem Cel/ Rev 3:249-255. SchochC, KohlmannA, DugasM, KernW, SchnittgerS , HaferlachT (2006): Impactof trisomy8 on expressionof genes locatedon chromosome8 in differentAML subgroups.Genes Chromosomes Cancer 45:1164-1168. Segel MJ,Paltiel0,ZimranA, Gottschalk-Sabag S, SchibiG, KrichevskiS, Ludkovski0, Ben Yehuda D (1998): Geographic variance in the frequency of the t(14;18) translocationin follicular lymphoma:an Israeli series comparedto the world. Blood Cells Mol Dis 24:62-72. SinclairPB, NachevaEP, LevershaM,TelfordN, ChangJ, ReidA. BenchA, ChampionK,HuntlyB, GreenAR (2000): Largedeletionsat the t(9;22)breakpointarecommonand may identifya poorprognosissubgroupof patientswith chronicmyeloid leukemia.Blood 95:738-743. SjoblomT. JonesS, Wood LD, ParsonsDW, LinJ. BarberTD, MandelkerD, LearyFU,PtakJ, Silliman N, Szabo S, BuckhaultsP, FarrellC, Meeh P, MarkowitzSD, Willis J, Dawson D, Willson JK, GazdarAF, HartiganJ, Wu L, Liu C, ParmigianiG, ParkBH, BachmanKE, PapadopoulosN, Vogelstein B, KinzlerKW, Velculescu VE (2006): The consensus coding sequences of human breastand colorectd cancers.Science 3 14:268-274.

REFERENCES

43

Smith MT, Zhang L, Wang Y, Hayes RB, Li G, Wiemels J, Dosemeci M, Titenko-HollandN, Xi L, KolachanaF,Yin S, RothmanN ( 1998): lncreasedtranslocationsandaneusomy in chromosomes8 and 2 I among workers exposed to benzene. Cancer Res 10:2 176-2 I8 I . Soda M, Choi YL. Enomoto M, Takada S, Yamashita Y, lshikawa S, Fujiwara S, Watanabe H, KurashinaK, HatanakaH, Bando M, OhnoS, lshikawaY,AburataniH, Niki T, SoharaY, Sugiyama Y, Mano H (2007): Identificationof the transformingEML4-ALK fusion gene in non-small-cell lung cancer. Nature 448561-566. Speicher MR, Carter NP (2005): The new cytogenetics: blurring the boundaries with molecular biology. Nat Rev Genet 6:782-792. TaylorAM (2001): Chromosomeinstability syndromes.Best Pract Res Clin Haematol 14:631-644. Tomlins SA, Rhodes DR, PernerS, DhanasekaranSM, Mehra R, Sun XW, VaramballyS, Cao X, TchindaJ, Kuefer R, Lee C, Montie JE, Shah RB,Pienta KJ, RubinMA, ChinnaiyanAM (2005): Recurrentfusion of TMPRSS2 and ETS transcriptionfactor genes in prostate cancer. Science 3 10:644-648. WangJCY, Dick JE (2005): Cancerstem cells: lessons from leukemia. Trmds Cell BiolI5:49&501. Wheeler DL, BarrettT, Benson DA, Bryant SH, Canese K, Church DM, DiCuccio M, Edgar R, FederhenS, HelmbergW, KentonDL, Khovayko0,LipmanDJ, MaddenTL, MaglottDR, Ostell J, PontiusJU. PruittKD, SchulerGD, SchrimlLM, SequeiraE, SherryST, SirotkinK, StarchenkoG, Suzek TO, Tatusov R, TatusovaTA, WagnerL, Yaschenko E (2005): Database resourcesof the National Center for Biotechnology Information.Nucleic Acid.7 Res 33:D39-D45. Wood LD, Parsons DW, Jones S, Lin J, Sjoblom T, Leary RJ, Shen D, Boca SM, BarberT, Ptak J, Silliman N, Szabo S, Dezso Z, Ustyanksky V, Nikolskaya T, Nikolsky Y, Karchin R, Wilson PA, Kaminker JS, Zhang Z, Croshaw R, Willis J, Dawson D, Shipitsin M, Willson JK, SukumarS, Polyak K, ParkBH, PethiyagodaCL, Pant PV, Ballinger DG, SparksAB, Hartigan J, Smith DR, Suh E, PapadopoulosN, BuckhaultsP, MarkowitzSD, ParmigianiG, Kinzler KW, Velculescu VE, Vogelstein B (2007): The genomic landscapes of human breast and colorectal cancers. Science 318:1108-1113. Zhang Y, Rowley JD (2006): Chromatin structuralelements and chromosomal translocations in leukemia. DNA Repair 5:1282-1 297.

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CHAPTER5

Acute Myeloid Leukemia

BERTIL JOHANSSON and CHRISTINEJ. HARRISON

Acute leukemiais a worldwidedisease with an incidenceof approximately4/100,000 per year;70% of the cases are acute myeloid leukemia(AML). Whereasacute lymphoblastic leukemia(ALL) predominatesin childhood,AML is by far the most commontype among adults,in whom the incidencerises steeply afterthe age of 55-60 years;the medianage is roughly 70 years. Men are slightly more often affected than women, and a male preponderance is also apparentin publishedAML with an abnormalkaryotype;however, the medianage of the publishedcases is only 45 years (Mitelmanet al., 2008). Thus, thereis definitely an age bias of the cytogenetic data on AML,with a clear underreportingof karyotypedcases in elderly patients. The salient pathologic feature of AML is the excessive accumulationof immature myeloid blasts in the bone marrow(BM). This maturationblock, a characteristicof acute leukemias,preventsnormal hematopoiesisand leads, directly or indirectly,to a lack of differentiatedgranulocytes(neutrophils,eosinophils, and basophils),monocytes, thrombocytes, and erythrocytes.Over the years, several attemptshave been made to classify AML into entities that are reproducible,contributeto a more profoundunderstandingof the disease biology, and areof prognosticand therapeuticimportance.A majorinitiative and a step forwardin this respect was takenby the cooperativeFrench-American-British (FAB) study group who in 1976 proposeda classificationof acute leukemias in which ALL and AML were separatedand subdividedinto three and six groups, respectively (Bennett et al., 1976). Initially, the FAB classification relied almost exclusively on morphologic criteria, but subsequent revisions included information gained from other investigations, mainly cytochemical and immunophenotypicanalyses (Bennett et al., 1985a, 1985b, 199I). Ultimately, the FAB classificationrecognizedthe following subgroups:minimally differentiatedAML (MO), AML without maturation(MI), AML with maturation (M2), acute promyelocytic leukemia (APL)-hypergranular/typical (M3) as well as microgranular/hypogranular/atypical (M3v). acute myelomonocytic leukemia (M4)-including the subtypeM4Eo with BM eosinophilia,acute monoblastic (M5a) and monocytic (M5b) leukemia, acute erythroleukemia(M6), and acute megakaryoblasticleukemia(M7). Althoughthis classificationwas of utmost importance,it has

Cancer Cytogenetics, Third Edition, edited by Sveme Heim and Felix Mitelman Copyright 0 2009 John Wiiey & Sons. Inc.

45

46

ACUTE MYELOIDLEUKEMIA

recently evolved toward the present World Health Organization(WHO) classification (Brunninget al., 2001). The rationalefor the WHO classificationis the incorporationof morphologic,immunophenotypic,genetic, and clinical features in an effort to define subgroups that are biologically homogeneous and have clinical relevance. Four categories are delineated: (1) AML with recurrentgenetic abnormalities,which at present compriset(8;21)(q22; q22), 1 lq23 translocations,t( 15;17)(q22;q21),and inv( 16)(p13q22);(2) AML with multilineage dysplasia; (3) therapy-relatedAML (t-AML) and myelodysplasticsyndromes (t-MDS); and (4)Ah4L not otherwise categorized. The most importantdifference comparedto FAB is the WHO definitionof AML as 220% myeloblastsin the blood or BM. Consideringthatmostcytogeneticstudiesto datehave used the FAB classification,itand the abbreviationsMCM7-are used in this chapter.

MOST AML HARBOR CLONAL CHROMOSOME ABNORMALITIES Chromosomebandinganalyses reveal acquired,clonal chromosomeabnormalitiesin the majorityof Ah4L patients,with the frequenciesandtypes of aberrationsbeing influencedby factors such as age, previous treatmentlgenotoxicexposure, gender, ethnidgeographic origin, and constitutionalgenetics, as exemplifiedbelow.

Impact of Age Numerousstudieshave shown thatpediatricA M L aremoreoften karyotypically abnormal than adult AML. In general, clonal changes are found in 70-80% of childhoodcases, whereasthe correspondingfractionin adultAML is 50-609’0 (Table5.1). Approximately 50% of all cytogenetically abnormal AML are pseudodiploid, in childrenas well as in adults,whereashypodiploidyis morecommonin adults(20%)than in pediatric AML (10%);the opposite is true for hyperdiploidy (25 versus 35%) (Mauritzsonet al., 2002; Forestieret al., 2003). However, karyotypiccomplexity does not differ in relation to age, with both childhood and adult AML harboringsingle changes in 60%, displayingtwo anomaliesin 15%,and having threeor more aberrations in 25% of all cases.

TABLE 5.1 Frequencies of Clonal Chromosomal Abnormalities in Larger Series of Pediatric and Adult Acute Myeloid Leukemias Adult AML

PediatricAML Frequency

Reference

Frequency

Reference

68% (1471217) 73% (249/340) 73% (21 11288) 76% (5601736) 76% (826/1083) 77% (369/478)

Lampert et al. (1991) Grimwadeet al. (1998) Forestieret al. (2003) Dusenbery et al. (2003) Barbaricet al. (2007) Raimondiet al. ( 1 999)

52% (631/1213) 52% (1335/2555) 54% (683/1272) 55% (653/1192) 57% (575/1003) 59% (728/1225)

Byrd et al. (2002) Bacher et al. (2005) Grimwadeet al. (1998) Sandersonet al. (2006) Schnittgeret al. (2002) Schoch et al. (2004)

MOST AMLHARBOR CLONALCHROMOSOMEABNORMALITIES

47

Severalchromosomechangesaremorecommonin childrenthanin adults,andvice versa (Table 5.2). For example, t( 1;22)(p13;q13),t(4;l l)(q21;q23), and t(7;12)(q36;p13)are almostexclusivelyseen in infantAML, t(5;l l)(q35;p15)andt(5;17)(q35;q21)mainlyoccur in children/adolescents,t(3;5)(q25;q35),t(6;9)(p22;q34),andt(7;1 1)(p15;p15)aretypically foundinyoungeradults, whereast( 1 ;3)(p36;q2l), t(4;12)(q12;~13),andcornplexkaryotypes with whole or partiallosses of chromosomes5 and 7 are primarilyseen in middle-agedor elderlypatients.The reasonsfor this age-relatedfrequencyvariationareunknown,butmost likely differencesin exposuresto “leukemogenicfactors”lie behindthe variability.

Impact of Previous Treatment/Genotoxic Exposure That previous therapywith chemotherapyand/orradiotherapyinfluences the karyotypic featuresseen in the ensuing AML (t-AML) has been known since the late 1970s. In the presentWHOclassification,two maint-AMLtypesarerecognized,one following exposure to alkylatingagentsand/orionizingradiationand one aftertreatmentwith DNA topoisomeraseI1 inhibitors.These two types differclinicallyas well as genetically.Briefly, previous treatmentwith alkylatorsis strongly associated with t-AML occurringsome years after exposure, often with a prior MDS phase. These leukemias are usually cytogenetically complex and hypodiploid,primarilyharboringgenomically unbalancedanomaliessuch as whole orpartiallosses of chromosomes5,7, and 17 as well as monosomyforchromosomes 18 and 21. RUNXl, RAS, and TP53 mutationsarefrequent.In contrast,t-AMLarisingafter treatmentwith drugs targetingDNA topoisomeraseI1 develops soon after exposure and usually withoutan antecedentMDS. Theseleukemiasarecytogeneticallycharacterizedby balanced translocationsin pseudodiploidkaryotypes.Different topoisomeraseI1 poisons have been suggestedto resultin differentaberrations,with the epipodophyllotoxinsmainly being associatedwith 1lq23 translocations,RAS, and BRAF mutationsand the anthracyclines with 16q22and21q22 translocationsandmutationsof KITandPTPNlJ (Mauritzson et al., 2006). et al., 2002; Smith et al., 2003; Pedersen-Bjergaard Othertherapeuticagents have also been linked to certainchromosomechanges. For example, AML following granulocytecolony-stimulatingfactor treatmentof pediatric patientswith aplasticanemiaor Kostmannsyndrome(severecongenitalgranulocytopenia) and AML occurringafter immunosuppressivetherapywith azathioprinehave both been associatedwith monosomy 7 (Kalraet al., 1995; Arnold et al., 1999). Little is known about the impact of prior occupational,environmental,or lifestyle exposureson AML-associatedkaryotypicfeatures,althoughthis importantquestionhas been addressedin numerousstudies. As early as the 1980s, it was suggested that AML occurringin individualsoccupationallyexposedto potentialmutagenic/carcinogenic agents were more often karyotypicallyabnormal,frequentlyshowing whole or partiallosses of chromosomes5 and 7 (Mitelmanet al., 1981). However, this correlationhas, with a few exceptions, not been confirmedin later studies (Craneet al., 1996; Albin et al., 2000). Similarly, even though significant associations between certain types of exposure and chromosome abnormalitieshave been reported,such as smoking and -7/de1(7q), $8, t(8;21)(q22;q22),andinv(16)(p13q22);alcoholand -5/de1(5q) and -7/de1(7q); paintsand t(8;21)(q22;q22);pesticidesand herbicidesand -5/de1(5q); and organicsolvents and +8 (Sandleret al., 1993;Craneet al., 1996; Davico et al., 1998; Albin et al., 2000; Moorman et al., 2002), these associationshave generallynot been verifiedin subsequentindependent patientcohorts.Thus,cautionis requiredbeforeconcludingthata particularenvironmental exposureis the cause of an AML with a certainchromosomechange.

8

+8 sole

t(4;l l)(q21;q23) -5/de1(5q) t(5;l l)(q31;q23) t(5;l l)(q35;p15) t(5;17)(q35;q21) t(6;9)(p22;q34) t(6;l l)(q27;q23) -7/del(7q) t(7;l l)(p15;p15)

+4 sole t(4;12)(ql2;pl3)

t(3;5)(q25;q35) t(3;12)(q26;p13)

t( 1;22)(p13;q13) der(1;7)(qlO;p10) t(l;l l)(q21;q23) t(2;3)(p1 1-23 ;q23-28) inv(3)(q21q26)

Aberrations

NUP98-HOXA9/HOXA I I / HOXA13 MNXI- E m 6 and MNXl expression

MLL-ARHGAP26 NUP98-NSDI NPMl -RAM DEK-NUP214 MLL-MLLT4

MLL-MLLTI I EVll expression EVII, GATA2 and RPNUEVII expression NPMl -MLFI ETV6/EVI1 and EVll expression RUNXI -MDSI/EVII/ RPL22P1 KIT mutations CHIC2ETV6 and GSX2 expression MLL-AFFl

RPNI-PRDM16 RBMl5-MKL1

Molecular Genetic Features

Variablemorphology,MO or M1


F>M F=M

50

Variablemorphology,MI, M2, M4, or M5

Poor Poor Favorable(?) Poor Favorable Poor Poor Poor Poor

M4 or M5, t-AML Variablemorphology,MO or M6, t-AML M4 or M5 M1, M2, or M4 M3v, no Auer rods MI, M2, or M4, dysplasia, basophilia,Auer rods M4 or M5 Variablemorphology,MO or M6, t-AML M2 or M4, trilineage dysplasia, Auer rods


F>M F=M M>F F=M F=M F=M F=M M>F M>F

Intermediatelpoor

Poor

Intermediate/poor Poor

M2 or M4 MO or MI, trilineage dysplasia, basophilia

55 60

F>M M>F

60

M>F

Poor

30 50

F=M M>F

Unclassifiablemorphology,M2 or M4, t-AML


60
F=M F>M M>F F>M F=M F=M Poor (?) Poor

Prognosis

Variablemorphology,M6, trilineagedysplasia Variablemorphology, dysmegakaryocytopoiesis

CharacteristicFeatures

Poor Intermediate/poor Poor Poor (?) Poor Poor

Median Age M4, dysmegakaryocytopoiesis M7, myelofibrosis,not Down syndrome Variablemorphology,t-AML M4 or M5 M2, dysmegakaryocytopoiesis Variablemorphology,dysmegakaryocytopoiesis

Gender

TABLE 5.2 Cytogenetic, Molecular Genetic, and Clinical Features of AML-Associated Chromosome Aberrations

P

(D

t( 15;17)(q22;q21) inv(16)(pl3q22) t( 16;21)(pl l;q22) i(17)(qIO) sole del(20q) sole +21 sole +22 sole -Y sole

t(l1;17)(q23;q21) t(l1;17)(q23;q25) t(l1;19)(q23;p13.1) t( 11; 19)(q23;p13.3) 4 1 3 sole

t(8;l6)(p1 1;p13) t(8;21)(q22;q22) t(9;1 l)(p21;q23) del(9q) sole t(9;22)(q34;qll) t( 10;12)(p12;q14) 10p12/1lq23 rear. + I 1 sole inv(1l)(p15q22) t(l1;2O)(p15;q12) t(11;17)(q23;q12)

RUNXI mutations

BCR-ABL1 PICALM-MLLTI 0 MLL-MLLTlO M U and FLT3 ITD NUP98-DDXI 0 NUP98-TOP I MLL-MLLTti/USPl/ ACACA ZBTBl -RARA MLL-SEPT9 MLL-ELL MU-MLLTI FLT3 expression,RUNXl mutations PMURARA CBFBMYHI 1 FUSIERG

MYST3-CREBBP R UNXl-R UNXlT l MLL-MLLT3

M4 or M5, hemophagocytosis,DIC, EML M2, granulocyticdysplasia, Auer rods, EML M5, EML, t-AML M1, M2, or M4, Auer rods M1 or M2, biphenotypic Variablemorphology,MO or M 1, biphenotypic M5 M1, M2, or M4, trilineage dysplasia, Auer rods Variablemorphology,t-AML Variablemorphology,M2 or M5, t-AML M4 or M5

Atypical M3, Pelger-like cells, DIC M4 or M5, t-AML M4 or M5, t-AML M4 or M5 (ALL or biphenotypic),t-AML Undifferentiated,MO or MI, trilineage dysplasia M3 or M3v, DIC, Auer rods M4Eo, Auer rods Variablemorphology,eosinophilia, hemophagocytosis Variablemorphology Variablemorphology Variablemorphology,MO, MI, or M2 Variablemorphology,M4, eosinophilia Variablemorphology, Auerrods

45 30 20 50 45 20 2 60 45 25 15

55 25 50
40 35 25 65 60 35 30 60

F>M M>F F=M M>F M>F F=M M>F M>F M>F F>M M>F M>F F=M F=M F=M M>F F=M F=M M>F M>F M>F M>F M>F M only

Favorable Favorable Poor Poor lntermediate/poor Intermediate/poor Intermediate/poor Intermediate

Intermediate/poor Poor (?) Poor Poor Poor

Poor Favorable Favorable/intermediate Intermediate Poor Poor Poor Poor Poor (?) Poor Poor (?)

50

ACUTE MYELOID LEUKEMIA

Impact of Gender SeveralAML-associatedabnormalitiesdisplay an unequalsex distribution(Table5.2). For example, t(1;22)(p13;ql3), t(4;l l)(q21;q23), t(8;16)(pll;p13), and t(l1;2O)(p15;q12)are clearlymorecommonin females,whereasthe oppositeis trueforder(I ;7)(qlO;plo), t(5;l I ) (q31;q23), and t( 1 1 ;17)(q23;q2I). Whethersuch gender-relateddifferencesin frequency reflectconstitutionalheterogeneityand/ordifferentiatrogenicand/orenvironmentalexposure is presentlyunknown.

Impact of GeographidEthnic Origin Mitelman and Levan (1978) were the first to describe differences in the incidence of chromosomeaberrationsin hematologicmalignanciesdiagnosedin differentpartsof the world. In a later review by Johanssonet al. (1991), who ascertainedclose to 1500 AML cases, significantfrequencyvariationwas identifiedfor -5, del(5q), +8, t(8;21)(q22;q22), and t(15: 17)(q22;q21)amongpatientsfrom Asia, Europe,and the UnitedStates.Although some of the observeddifferencesmay have been fortuitous,the overall findingsstrongly suggested heterogeneityin geographicfrequencyof AML-associatedabnormalities.The conclusion was that, although genetics may play a role, differences in environmental exposure were the more likely explanation.Since then, a few translocationshave been shown to be particularlycommon in some geographidethnicgroups,such as t(7;l l)(p15; p15) in patients from Asia (Kwong and Pang, 1999) and t(6;11)(q27;q23) in African Americansin the United States (Blum et al., 2004).

Impact of Constitutional Genetics Thereare some examplesof constitutionalgenetic abnormalitiesthatinfluencethe risk of AML as well as the type and frequencyof acquiredaberrations.Forexample,childrenwith Down syndrome(DS) havea pronouncedriskof developingAML, in particularthe subtype M7. The genetic featuresof DS-related AML differ from those seen in non-DS-AML: GATAl mutations,dup(lq), del(6q), del(7p), dup(7q), +8, 1 I , del( l6q), and +21 are significantly more common in DS-AML, whereas t( 1;22)(p13;q13), t(8;21 )(q22;q22), 1 I q23 rearrangements, t( 15;17)(q22;q21 ), and inv( 16)(pl3q22) are much more frequent in non-DS-AML,being extremelyrarein DS-AML (Forestieret al., 2008). Thus,DS-AML is clearly a distinct entity,as recognized by the present WHO classification. A few Mendeliandisordersare known to increase the risk of AML with characteristic chromosomalabnormalities.For example, AML in patientswith the autosomalrecessive chromosomebreakagesyndromeFanconi anemia shows gain of lq (throughdup(lq) or unbalanced 1q translocations)and/or monosomy 7 in most instances (Auerbach and Allen, 1991). It is noteworthythat AML occumng in patientswith Bloom syndromeis also associatedwith loss of chromosome7 material(Poppeet al., 2001). Duringthe last decade, numerousstudies have investigatedthe possibility that genetic polymorphisms,forexamplein detoxificationgenes andthose involvedin DNA repair,may predisposeindividualsto AML, particularlyafterpriorchemotherapyand/orradiotherapy. However, in an extensive, recent review, Seedhouse and Russell (2007) concludedthat, although defects in the mismatch repair pathway are likely to be a factor in t-AML susceptibility,analysesof a large numberof othergenes have providedresultsthatare less clear and often contradictory.Interestingly,it was recentlyreportedthatone specific allele

+

CHARACTERISTICCHROMOSOMEABNORMALITIESIN AML

51

of the xerodennapigmentosumgroup-D gene is significantlyassociatedwith the risk of developingAML with del(5q) andor del(7q) (Smith et al., 2007).

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML Thecytogenetic,moleculargenetic,andclinicalfeaturesof AML-associatednumericaland structuralabnormalities,reportedin a sufficient numberto allow delineationof clinicogenetic associations,are summarizedbelow in orderof chromosomenumber;aberrations involvingthe samechromosomearelisted frompterto qter.Foreach anomaly,the Mitelman Databaseof ChromosomeAberrationsin Cancer(Mitelmanet al., 2008) has been searched to identifythe numberof cases reported,the frequencyand type of secondarychanges,age and sex distribution,and morphologicsubtypes.Forthe sakeof brevity,this databaseis not referredto below. As the Mitelman databasecontains all cytogenetic referencesto the variousabnormalities,andin orderto minimizethenumberof referencesin the text,only the most pertinentstudies, mainly initial reportsand largerseries, are referredto. Throughout,we have emphasizedthe cytogeneticfeaturesandthe clinical implications of theaberrations,whereasthedescriptionsof themoleculargeneticlbiologicconsequences of the changesare less detailed,as they lie outsidethe main scope of this book. The genes rearrangedas a resultof an abnormalityarealways mentionedto allow moreinformationto be retrievedfrompertinentdatabaseson the Internet.The moleculargenetic findingsas well as someclinicalandprognosticfeaturesassociatedwith thevariousabnormalitiesarebriefly summarizedin Table 5.2.

Approximately30 AML cases with t( 1 ;3) (Fig. 5.1) have been reported,with the translocation being the sole chromosomalaberrationin three-quartersof the cases. The only recurrentadditionalchangesidentifiedto datearemonosomy2 anddel(5q).Thatsecondary aberrationsare genomically unbalancedseems to be a rule not only in acute leukemias but also in cancer cytogenetics in general (Johanssonet al., 1994, 1996). However,why

1

3

FIGURE 5.1 The t( 1;3)(p36;q21) is strongly associated with AML with dysmegakaryocytopoiesis. Arrows indicate breakpoints.

52

ACUTE MYELOID LEUKEMIA

primaryabnormalitiesalmost always are cytogenetically balanced whereas secondary anomaliesmostly are unbalancedis unknown. Shimizuet al. (2000) showedthatthe 3q21 breakpointsclusteredclose to the ribophorin I (RPNI) gene, which is ubiquitouslyexpressedat high levels. They then isolateda novel gene at 1p36, thePR domaincontaining16 (PRDM16)gene (previouslyMELI), encodinga zinc fingerproteinhomologousto MDS1EVI1 (myelodysplasiasyndromel/ecotropicviral integrationsite I), which was ectopically expressedonly in cells with t( 1;3) (Mochizuki et al., 2000). This suggested that PRDMZ6 was transcriptionallyactivated by RPNI. However, it was subsequentlyshown that PRDM16 expressionis not restrictedto AML with t(1;3) and thatthe lp36 breakpointsvary extensively (Lahortigaet al., 2004a). Thus, the moleculargenetic consequencesof the t( 1 ;3) seem to be heterogeneous. The t( 1 ;3) is equally common in females and males and mainly occurs in adults;the median age among publishedcases is 60 years. The majorityof t( 1;3)-positivemyeloid malignanciesare AML but many, includingthe firstpublishedseries (Moiret al., 1984), are diagnosedduringan often shortMDS phase characterizedby trilineagedysplasia.in ppicular dyserythropoiesis and a marked dysmegakaryocytopoiesis (Bloomfield et al., 1985; Secker-Walkeret al., 1995). Welbornet al. ( I 987) describedpatientswith t( 1;3)-positiveAML/MDSas typically middle-agedand severely anemic,with macrocytosis and a relativelyhigh plateletcount. The dysmegakaryocytopoieticfeaturesand the involvementof 3q2 I soon led to the suggestion thatthe t( I ;3) mightbe a variantof inv(3) (q21926)/t(3;3)(92I;q26)(Bloomfieldet al., 1985;Secker-Walkeretal., 1995). Similarto these rearrangements,AML with t( 1;3) are often difficult to classify morphologically, althoughmost areclassifiedas M4 (Bloomfieldet al., 1985;Welbornet al., 1987;Shimizu et al., 2000). Prior genotoxic exposure has been reportedin 10-15% of t(l;3)-positive AML.In contrastto mostotherbalancedtranslocationsin t-AML,the t( 1 ;3)is not strongly associated with topoisomeraseII inhibitorsbut ratherwith radiotherapyand alkylating agents (Welborn et al., 1987; Block et al., 2002; Charrinet al., 2002; Mauritzsonet al., 2002). A dismal outcome of t(l;3)-positive AML, with most cases being virtually nonresponsiveto conventionalchemotherapy,has been emphasized.

Thistranslocationhas been reportedin close to 40 AMLcases andwas the sole changein the majority(75%)of the cases. Those with secondaryaberrationsare often high hyperdiploid or hypotriploid,with chromosomenumbersrangingfrom 5 1 to 6 I . The t( 1;22) rearrangesthe RNA bindingmotif protein15 (RBMIS) gene (formerlyOTT or OZTI)and the megakaryoblasticleukemia(translocation)1 (MKLI) gene (previously MAL)at Ipl3and22q13,respectively(Maetal.,2001; Mercheretal.,2001). Althoughboth reciprocal chimeric transcriptsare expressed, the RBMlS/MKLI, transcribedfrom the derivativechromosome22, was expectedto be the pathogeneticone becauseit containedall functionalmotifsencodedby each gene. This was confirmedby the identificationof a threeway translocationthatresultedin a der(22)t(1 ;22) but not in a der(1 )t( I ;22).The leukemogenic mechanismof RBMIYMKLI remainsto be elucidated. The firstreportedt( 1 ;22)-positiveAML was classifiedas infantacuteerythroidleukemia (FTWCL, 1984a); however, this diagnosis was made several years before criteriafor the diagnosisof acutemegakaryoblasticleukemiawere published.All ensuingcases havebeen M7, and since the early 1990s, it has become apparentthat this translocationis pathognomonic for AML M7 in young children,most often infants without DS and withoutprior

CHARACTERISTICCHROMOSOME ABNORMALITIES IN AML

53

MDS or a transientleukemoidreaction(Baruchelet al., 1991; Carrollet al., 1991; Lion et al., 1992;Bernsteinet al., 2000;Dastugueet al., 2002). Thepatientstypicallypresentwith hepatosplenomegaly,anemia, thrombocytopenia,and BM myelofibrosis.There is a pronounced female preponderancewith a sex ratio (SR) of 2.0. Early reports of t(1;22) emphasizedthatit conferreda poorprognosisandthatstem cell transplantation (SCT) was indicated,but morerecently,the t( 1;22) has been associatedwith an intermediate outcome amongAML M7, with an event-freesurvivalof 50%at 3 yearsafterintensivetherapywith chemotherapyalone or with SCT (Dastugueet al., 2002).

der(l;7)(qlO;pIO) An unbalanced whole-arm translocationbetween chromosomes 1 and 7 (Fig. 5.2), resulting in gain of l q and loss of 7q, is found in roughly 0.5% of cytogenetically abnormalAML. However,some cases may go undetectedif the chromosomemorphology is poor because the der(1 ;7) may be misinterpretedas a +del( lp) and monosomy7. It is the sole change in two thirdsof the cases, while amongthe remainderthe most frequent secondarychange is f8. The initial studies of this translocationreportedthatthe breakpointswere locatedvery close to thecentromeresof bothchromosomes,with thecentromeremost likely belongingto chromosome 1. It was therefore initially described as “+der(l)t(l;7)(pll;pl1),-7” (Geraedts et al., 1980; Scheres et al., 1984). However, with the advent of in situ hybridizationtechniques and centromere-specificprobes, it was later revealed that the 1;7-translocation containeda satelliteDNA fromboth chromosomes(Alitalo et al., 1989; Nederlofet al., 1989).Thus, this abnormalityis a truewhole-armtranslocationthatshould be designatedder(1;7)(qI0;plo), anda karyotypeharboringit as thesole anomalyshouldbe written46,XX/XY, 1,der(1 ;7)(qlO;p10). Wanget al. (2003) performeddetailedmolecular genetic analyses of the der(l;7) showing that the centromeric fusion resulted from recombinationbetweenthe two alphoidsand thatthe breakpointsvariedextensivelywithin each alphoidcluster.Consideringthatit is unlikelythatthereis a specific targetgene at or near the variablebreakpoints,they concludedthat the pathogeneticallyimportantconsequence was probablyone of gene dosage. However,as for most genomic imbalances,the relevantgene expressionchanges remainunknown. der(l;7) is exceedingly rarein childhood AML; cases showing this aberrationhave a medianage of approximately60 years. It is morecommon in males, with an SR of 2.0. Most

+

+1

7

FIGURE 5.2 The whole-arm der(1;7)(qlO;pIO), which leads to gain of Iq and loss of 7q, is associated with 1-AML. The arrow indicates the centromeric breakpoints.

54

ACUTE MYELOID LEUKEMIA

der(1 ;7)-positivemyeloid malignanciesare initiallydiagnosedas MDS, but25%presentas full-fledged AML and 10% as chronic myeloproliferativedisorders(MPD). The AML morphologyis quite heterogeneouswith no subtypebeing more common. Several cases remainunclassifiable,in line with othert-AML.In fact, der(1;7)is stronglyassociatedwith prior iatrogenicexposureto alkylatingagents (Schereset al., 1985; Pedersen, 1992a) and has been shown to be significantlymorecommonin t-AMLthanin de novo AML;3 0 4 0 % of published der( 1 ;7)-positive myeloid malignancies have been diagnosed in patients previously treatedwith chemotherapyand/or radiotherapy(Pedersen,1992a; Mauritzson et al., 2002; Hsiaoet al., 2006; Sanadaet al., 2007). Severalinvestigatorshavereportedthat der(1 ;7) confersa poorprognosis,with patientspreviouslyexposed to genotoxictreatment andor cases with secondary changes having a particularly dismal outcome (Pedersen,1992a:Hsiao et al., 2006). Althoughthe poor survivaloften has been attributed to the del(7q) generatedthroughthe der(1;7), this may not be the sole, or even a correct, explanation.Sanadaet al. (2007) comparedMDS with der(1 ;7) with those with -7/de1(7q) and showed that the der(I ;7)-positive cases had lower blast counts, higher hemoglobin concentrations,slower progressionto AML, and significantlybetteroutcome than MDS with -7/de1(7q). Nevertheless,approximately50%of MDS with der(I ;7) transformedto AML after a median durationof 1 year, with median survivalof only 2 years.

t(1;l l)(q21;q23) The t( 1 ; I 1) is the fifth most common I lq23 translocationin unselected AML series, with only t(6;1I )(q27;q23),t(9;1 l)(p2 l;q23), lop121I 1q23 rearrangements, and t( I 1 ;19)(q23; p13) being more common.The t( 1;l I ) is the sole abnormalityin most instances;the only recurrentsecondarychange to date is 19. Tse et al. (1995) reportedthat t( 1;11) leads to a fusion between M U and M U T i i (previouslyA F l q ) and suggested that the pathogeneticallyimportanttranscriptwas the MLUMUTlI encodedby the der(1I)t( I ;I I); this conclusionwas based on the findingthat the reciprocalfusion on the der(1) did not give rise to an open readingframein one of the analyzedcases. Morerecently,the samegroupshowed thatelevatedexpressionof M U T I 1 is an adverseprognosticfactorin childhoodAMLas well as in adultMDS (Tse et al., 2004). A general summaryof the pathogeneticimpactof variousMLL chimerasis given in the 1 1q23 Rearrangementssection below. Thet( 1 ;1 1) is morecommonin womenthanin men;the SR is 1.5.Witha few exceptions, it only occursin pediatric,often infant,AML. Mostt(1;1 I)-positivecases areM4 or M5, and in contrastto manyotherMLL translocations,the t( I ;1 1 ) doesnot seem to be associatedwith prior genotoxic therapy (Harrisonet al., 1998; Busson-Le Coniat et al., 1999). The prognosticimpact of this rare abnormalityis unclear. However, based on the study by Busson-LeConiatet al. (1999), who reportedthatfive out of six patientsrelapsed,it seems reasonableto conclude that it is associated with a dismal outcome.

+

t(2;3)( pl 1-23iq23-28) Close to 40 AML cases with t(2:3) (Fig. 5.3) have been published.As seen from the designationgiven above, the reportedbreakpointshave been quite variable,althoughmost haveinvolved2p2 1-23 and3q26-28. The t(2;3)is the sole chromosomalaberrationin 50%, withthe mostcommonsecondarychange,monosomy7, being seen in one thirdof the cases.

CHARACTERISTICCHROMOSOME ABNORMALITIES IN AML

2

55

3

FIGURE 5.3 The t(2;3)(p23;q28) is associated with AML M2 and dysmegakaryocytopoiesis. Arrows indicatebreakpoints.

Madrigal et al. (2006) identified a breakpointclose to EVII at 3q26 and Poppe et al. (2006) showed that EVII was overexpressedin t(2;3)-positive AML.In a detailed analysis of six cases, Trubiaet al. (2006) reportedthat while the 2p breakpointswere somewhatheterogeneous,involving, for example, the zinger finger gene BCLZ ZA or the thyroidadenomaassociatedgene at 2p 16-2 I, all the 3q breakpointsmapped5’ of EVII, which was overexpressedin all investigatedcases. Thus, aberrantexpressionof this gene seems to be the pathogeneticallyimportantoutcome of the t(2;3). Consideringthatt(2;3)is rare,occurringin only 0.5%of adultAML (Trubiaetal., 2006), it is not surprisingthatrelativelylittleis knownaboutitsclinicalandprognosticimplications.To date, only a few pediatrict(2;3)-positiveAML cases have been reported;most patientsare adults, with a median age of 50 years. There is no clear-cutgender-relatedfrequency difference. The vast majority is de nova AML, mainly M2, and often associated with dysplastic megakaryocytesand near-normalplatelet counts, featuresthat resemble other myeloid disorderswith 3q26 abnormalitiesand EVZl overexpression.Furthersupportfor a close relationshipwithother3q26rearrangements comes fromthefactthatmonosomy7 is the most common secondary change, as usual in AML with rearrangementsinvolving this chromosomeband,and thatthe prognosishas been reportedto be poor (Trubiaet al., 2006).

inv(3)(q21q26)/t(3;3)(q21;q26) The inv(3) or t(3;3) (Fig. 5.4) is foundin ~ 1 of %cytogeneticallyabnormalAML, with the inversion being twice as common as the translocation.The inv(3) may be even more frequentconsidering that it easily escapes detection, in particularif the chromosome morphologyis poor.The inv(3)/t(3;3)is the sole cytogeneticchangein approximately40% of cases and is hence a primaryAML-associatedaberration.However, it is also relatively commonin CMLblast crisis (BC) (Chapter7). The only secondarychangefoundin a large proportionof inv(3)/t(3;3)-positiveAML is monosomy 7, which occurs in almost 50%of cases. Otherrecurrentbut less frequentchangesinclude del(5q), +8, and +21. Of these, only trisomy 8 is relativelycommon in inv(3)/t(3;3)-positiveCML. Involvementof EVII,which encodes a zinc fingertranscriptionfactor,in inv(3)/t(3;3)positive AML was firstreportedby Fichelson et al. (1992) and Morishitaet al. (1992) who showedthatthis gene, thoughnot normallyexpressedin hematopoieticcells, was activated in such leukemias. Subsequentstudies have revealed that the genomic breakpointsvary

56

ACUTE MYELOID LEUKEMIA

3

FIGURE 5.4 The inv(3)(q21q26) (left) and t(3;3)(q21;q26) (right) are strongly associated with prominent dysmegakaryocytopoiesis. Arrows indicate breakpoints.

substantiallyandthatactivationof EVll occurshy rearrangements mappingto a largeregion surroundingthe gene, with breakpointsin t(3;3) being 5' of EVII and breakpointsin inv(3) being 3' of EVZl (Levy et al., 1994; Suzukawaetal., 1994). However,the moleculargenetic consequencesof inv(3)/t(3;3)are clearly more complex than "simple"overexpressionof EVZI. Forexample,it has been shown that this gene is also expressedin 10-20% of AML cases without visible 3q2lq26 abnormalities.In fact, inv(3)/t(3;3)-positiveAML constitutesonly roughly 10%of AMLwith high EVll expression.Clearly,activationof EVIl may occurthroughvariousmechanisms.EVII expressionhas been describedas an independent prognostic factor within the intermediaterisk karyotypicgroup (Russell et al., 1994; Langabeeret al., 2001; Barjestehvan Waalwijkvan Doom-Khosrovaniet al., 2003). The 3q21 breakpointshave been shown to clusterin a regionclose to RPNI,suggesting thatintroductionof RPNI enhancerelementsupstreamor downstreamof EVII leadsto its ectopicexpression(Suzukawaetal., 1994).In addition,anRPNI/EVII fusiontranscriptwas identifiedin some cases (Pekarskyet al., 1997; Martinelliet al., 2003). Since not all 3q21 breakpointsare located close to RPN1, it is possible that other fusion transcriptsor aberrantlyexpressed genes are also associated with inv(3)/t(3;3).In fact, expression of GATAZ at 3q21 has been shown to be deregulatedin AML with 3q21q26rearrangements (Wieseret al., 2000; Lahortigaet al., 2004b). Takentogether,the molecularpathogenetic outcomeof 3q2Lq26 aberrationsis heterogeneous,seemingly very complex, and involves expression of E V l l , GATA2, and RPNUEVII. inv(3)/t(3;3) is very rare in pediatric AML. The change is characteristicfor adult AML, with a median age of 50 years. It is seen equally oftenin males and females. The first 3q21q26 aberrations,initially described as ins(3;3)(q21;q21q26) or ins(3;3)(q26; q21q26), although later reinterpretedas t(3;3), were published by Rowley and Potter (1976) and Golomb et al. (1978). Soon afterward,this translocationwas associated with dysplasticmegakaryocytesand increasedplatelets(Sweet et al., 1979). A few years later, the more common inv(3) was identified and also shown to correlate with dysmegakaryocytopoiesis(Bernsteinet al., 1982). Studies of several large patientseries have since confirmed the existence of a characteristic"3q2lq26 syndrome" (Bitter et al., 1985; Grigget al., 1993; Fonatschet al., 1994; Secker-Walkeret d., 1995; Charrin et al., 2002). The above-mentionedstudies have clearly shown that AML with inv(3)/t(3;3) is associated with normal or, less frequently,elevated platelets; an increased numberof

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

57

(micro)megakaryocytes;frequently an antecedent MDS phase; trilineage dysplasia; a variable FAB morphology; often fibrosis or increased reticulin in the BM; and an immunophenotypecharacterizedby expression of CD7, CD13, CDI5, CD 18, CD33, CD34, CD38, CDw65, and HLA-DR. Interestingly,several case reportshave indicated an association with diabetes insipidus (Miiller et al., 2002). The prognosis of inv(3)/ t(3;3)-positiveAML is universallypoor, with minimal or no responseto chemotherapy and very few long-term survivors. Advanced age and high white blood cell counts at diagnosis seem to confer an even worse outcome (Weisser et al., 2007). Although the value of allogeneic SCT has been questioned (Secker-Walkeret al., 1995; Reiter et al., 2000), more recent data suggest that this patientgroup perhapsmay benefit from such treatment(Weisser et al., 2007).

t(3;5)(q21-25;q31-35) Morethan50 A M L cases with a translocationbetweenthe long armsof chromosomes3 and 5 have been reported.The locationsof the breakpointshave been quite variable,but most aberrationshave been describedas eithert(3;5)(q21;q31) or t(3;5)(q25;q34).In principle, these could representtwo differentrearrangements, but it seems morelikely thatthey refer to one and the same abnormality.In fact, Raimondiet al. (1989), reviewing t(3;5)-positive AML with initiallydifferent3q and 5q breakpoints,concludedthatthe breaksmappedto 3q25 and5q34 in all of them and thatthey,hence,harboredthe sametranslocation.The fact thatthe t(3;5) subsequentlywas shownto involve the MLFl andNPMI genes at 3q25 and 5q35, respectively, furthersupportsthis conclusion. Thus, this abnormalityshould be designatedt(3;5)(q25;q35).The t(3;5)is the sole changein approximately80%of the cases. The only recurrentsecondarychanges have been trisomy 8 and monosomy for chromosomes 12 and 18. Yoneda-Katoet al. (1996) reportedthat the t(3;5) results in a fusion between the nucleophosmin(NPMI) andthe MLFl (myelodysplasialmyeloidleukemiafactor1) genes. TheNPMZ/MLFZ chimera,transcribedfromtheder(5)t(3;5),was shownto encodeaprotein thatis transportedto the nucleusandexpressedat high levels mainly in the nucleolus-the normalMLFl is otherwiseusuallylocatedin thecytoplasm.TheyhypothesizedthatNF'M I traffickingsignals direct MLFl to an inappropriatecellular compartment.Subsequent studieshaveconfirmedthe involvementof thesegenes in t(3;5)-positivecases andhave also shown that ectopic nuclear MLFl positivity is specific for AML with this abnormality (Arberet al., 2003; Falini et al., 2006). The leukemogenicimpact of the NPML/MLFl proteinremainsto be clarified,but since MLFl has been shown to inhibiterythropoietininduceddifferentiation,it has been suggestedthatit interfereswith erythroiddifferentiation (Naoe et al., 2006; Falini et al., 2007). This may also explain the preponderanceof this fusion gene in AML M6 (see below). AML with t(3;5) are equallycommonin women and men and mainly occur in younger patients;the median age is 30 years. None of the reportedcases has been associatedwith previousradiotherapyor chemotherapy;hence, t(3;5)-positiveAML is typically de novo. No clear-cutassociationwith any specific morphologyhas been established,but thereis a greater-than-expected frequency,at presentroughly25%,of the M6 subtypeamongt(3;5)positive AML. On the otherhand,this translocationis seen in less than 2% of unselected, A moregeneralfeatureof t(3;5)-positivecases, cytogeneticallyabnormalerythroleukemias. shared with many other AML with aberrationsinvolving 3q, is a prior MDS phase, a trilineage dysplasia, and an increased number of (micro)megakaryocytes,although in

58

ACUTE MYELOID LEUKEMIA

contrastto inv(3)/t(3;3),the plateletcounts are usually low (Raimondiet al., 1989; Grigg et al., 1993; Secker-Walkeret al., 1995). A few case reportshave indicatedan association between t(3;5) and acute febrile neutrophilicdermatosis, that is, Sweet’s syndrome (Billstromet al., 1990). Initially,the prognosisof t(3;5)-positiveAML patientswas found to be poor, with early relapses. However,several long-termsurvivorshave been reported afterallogeneicSCT (Raimondiet al., 1989;Grigget al., 1993; Secker-Walkeret al., 1995; Arberet al., 2003).

t(3;12)(q26;pl3) Close to 30 AML cases with t(3;12) have been published,with the translocationbeing the sole change in 60%.Thoughclearly a primaryAML-associatedabnormality,the translocation is also found,albeit rarely,in CML BC (Chapter7). The only recurrentsecondary changenoted in t(3;12)-positiveAML has been monosomy7; this aberrationhas not been reportedin CML cases with t(3;12). Raynaudet al. (1996) showed that all the 1 2 ~ 1 3breakpointsoccurredwithin EW6 (ets variant gene 6), a gene initially denoted TEL for “translocation,Ets, leukemia” (Golub et al., 1994). In contrast,the 3q26 breakpointswere quite variable, occurring both 5’ and 3’ of EVI1. Soon afterward,Peeters et al. (1997) reportedthat the t(3;12) resulted in a fusion between ETV6 and EVII. As the ETV6 gene did not contributeany functional domains to the chimera, it was suggested that the functionally important outcome might be aberrantexpressionof EVZI, driven by the Em6 promoter.Further studies have confumed the presence of ETWEVII transcriptsand/or increasedexpression of EVIl in t(3;12)-positiveAML (Iwase et al., 1998; Langabeeret al., 2001; Poppe et al., 2006). Despite the fact that the first t(3;12)-positive case was an infant AML (Massaad et al., 1990), t(3;12) is very rarein children.The vast majorityoccurs in adults, with a median age of 50 years. There is a male preponderancewith an SR of 1.5. The clinical featuresinclude priorMDS that oftenrapidlyprogressesto AML with a variable-often unclassifiable-morphology, dysplastic megakaryocytes, normal or decreased platelet counts, and a dismal prognosis (Secker-Walkeret al., 1995; Raynaudet al., 1996; Iwase et al., 1998; Voutsadakisand Maillard,2003).

t(3;21)(q26;q22) This aberration(Fig. 5.5) is somewhatmorecommonin CMLthanin AML, and it is also found in MDS and MPD (Chapters6-8). To date, approximately50 AML cases with

3

21

FIGURE 5.5 The t(3;21)(q26;q22) is associated with 1-AML. Arrows indicate breakpoints.

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

59

t(3;21) have been reported,with the translocationbeing the sole change in close to 50%. Recurrentadditionalchanges include monosomy 7, trisomy for chromosomes8 and 12, and gain of the der(21)t(3;21);apartfrom -7, these are also common in t(3;21)-positive CML. Nucifora et al. (1993a) reported that RUNXI (runt-relatedtranscriptionfactor I , previously AMLZ) was rearrangedas a consequence of the t(3;21). This gene is homologous to the Drosophila melanogaster segmentation gene runt, the locus of which was first identified by Nusslein-Volhardand Wieschaus (1980) who named it so becausethe mutantlarvaewere significantlysmallerthanthe wild type ones, that is, as in "theruntof the litter."Nuciforaet al. (1993a) showed thatthe promoterregion as well as the sequences of RUNXI homologous to runt moved to the der(3)t(3;21), and suggested three possible molecular genetic outcomes of the translocation:(1) the 5' part of R U M 1 fuses to a gene on 3q26 generatinga chimeric fusion transcript;(2) a rearranged,truncatedRUiVXZ as such plays a leukemogenicrole; or (3) the promoterof R U M 1 leads to aberrantexpressionof a gene on 3q26 otherwiseunexpressed-the EVIl was considered a likely target. The molecular genetic features of the t(3;21) were subsequentlyshown to be rathercomplex, involving intergenicsplicing and generation of multipletranscriptsbetween RUNXI and threeunrelatedgenes at 3q26, namely, EVZI, MDSZ, and the ribosomalproteinL22 pseudogene 1 RPL22Pl (formerlyEAP) (Nucifora and Rowley, 1995). Furtherstudies of the chimeric protein have shown that it is a transcriptionrepressor,thatit upregulatesthe cell cycle andblocks granulocyticdifferentiation, and that it induces myeloid leukemia in mice (Nucifora et al., 2006; Tokita et al., 2007). The t(3;21) is slightly more common in males than in females, with an SR of 1.3. It mainly occurs in adults with a median of 60 years. Already the initial reportsof t(3;21) emphasizedits associationwith acute transformationof MDSMPD and/orpriorchemotherapy(Akahoshiet al., 1987; Rubinet al., 1987), and laterstudies have confirmedthat t(3;21) is a recurringabnormalityin t-AML and thatit is stronglycorrelatedwith previous treatmentwith DNA topoisomeraseI1 poisons; in fact, almost 50%of all t(3;21)-positive AML aretreatment-related (Rubinet al., 1990;Pedersen-Bjergaard et al., 1994;Mauritzson et al., 2002; Slovaket al., 2002). Morphologically,most of the cases areunclassifiable,with the remainingones mainly being M2 or M4.The t(3;21) has been associatedwith a poor prognosis by most investigators.

Trisomy 4 Trisomy 4 is found in roughly 1% of all cytogeneticallyabnormalAML; it is the sole aberrationin one thirdof the cases. Interestingly,thereis an associationbetween f 4 and doubleminutes(dmin),sometimeswith $4 in the stemlineanddminonly in a subcloneand occasionallyvice versa. Trisomy4 is also a relativelycommon secondarychangein AML with t(8;21)(q22;q22),occurringin 1-296 of such cases. The moleculargenetic consequencesof +4 are,as for numericalchromosomechanges in general, unknown. Possible mechanismsinclude global gene expression alterations becauseof the gene dosageeffect generatedby the trisomyandduplicationof rearrangedor mutatedgenes on chromosome4. No studieshave as yet specificallyaddressedthe general expressionpatternsin AML with f 4 . Instead,most analyseshave focusedon the KITgene at 4q12, which encodes a receptortyrosine kinase related to FLT3. Although Ferrari et al. ( 1 993) reportedoverexpressionof KIT in one case with +4 as comparedto AML

60

ACUTE MYELOIDLEUKEMIA

withoutthis abnormality,suggestingthatthis couldplay a pathogeneticrole, KIT mutations have later received more attention.Beghini et al. (2000) showed that +4 resulted in duplicationof a mutatedKIT allele in an AML that also harboreda t(8;21), and they later reportedduplicationof a mutatedKIT gene in additionalcases with t(8;21) and +4 as well as in two out of six AML with +4 as the sole change (Beghini et al., 2004). Similarly, Schnittgeret al. (2006) reportedKIT mutationsin two cases with +4 as the sole change. Thus,thereis an association,albeit not an absoluteone, between the presenceof a mutated Kfl gene and trisomy4. The dmin in AML with +4 areknownto harborthe MYC gene (Govberget al., 2000). It was initiallysurmisedthatthis gene was the targetof the amplification,based mainlyon its importancein other hematologicmalignancies, suchas ALL, lymphomas,and multiple myeloma(Chapters9 and 10).However,detailedmappingandexpressionanalysesof MYCcontainingdminhave revealed thatthey harborseveralgenes in additionto MYC and that this gene is not overexpressed,in effect excludingMYC as the likely targetgene (Storlazzi et al., 2006). Trisomy4 as the sole changeis morecommonin women thanin men, with an SR of 1.6, and primarilyoccurs in adults(medianage of 55 years). Most cases are morphologically classified as M2 or M4. In the initial reportof +4 as a single change in AML, Mecucci et al. ( 1 986) suggested that it characterizeda novel subgroupof AML not associated with priorgenotoxic exposure.Indeed, several studies have since confirmedthat trisomy 4-positiveAML mainly arede n o w and have also shownthatthey, possibly,areassociated with markedleukocytosis,extramedullary leukemia(EML),andhand-mirror appearanceof the blasts(Weberet al., 1990;Pedersen,I992b;UKCCG,1992a;Suenagaet al., 1993).The prognosticimpactof +4 is unclear,but based on a review of 30 cases, Guptaet al. (2003) concludedthatthe outcome appearedto be poor comparedto othercytogeneticentitiesin the intermediaterisk group. In fact, and as will be mentioned in the relevant sections below, several AML-associatedtrisomies are associated with an intermediateto poor prognosiswhenfoundas singleanomalies;apartfrom f4, thisis also truefor +8, 1 1, and 13.

+

+

t(4;12)(q12;pl3)

Approximately25 AML cases with t(4;12) (Fig. 5.6) have been published.It has been the sole changein 70%of these;the only recurrentsecondarychangeshave been -7, - 1 1, and i( 17q).

4-

12

FIGURE 5.6 The t(4: 12)(q 12;p 13) is associated with AML MO or M1,trilineage dysplasia, and basophilia. Arrows indicate breakpoints.

CHARACTERISTICCHROMOSOME ABNORMALITIES IN AML

61

Cools et al. (1999) showed thatthe t(4;12) leads to a fusion between CHIC2(cysteinerich hydrophobicdomain2 gene, previouslyBTL) and ETV6, with expressiononly of the CHICYEW6 transcript.However,the moleculargeneticoutcomeof this translocationhas turned out to be more complex than a ”simple” in-frame fusion. Not only is there a breakpointheterogeneityat 4q12, but also some t(4;12)-positivecases thatdo not express the CHIC2/ETV6 fusion (Oderoet al., 2001; Cools et al., 2002). For this reason,the latter groupproposedanotherleukemogenicmechanismof the t(4;12), namely deregulationof genes in 4q12. In fact, they foundectopicexpressionof the homeoboxgene GSX2 (initially GSH2), located in the vicinity of the 4q12 breakpoints,in all t(4;12)-positive cases, irrespectiveof whetherthe CHIC2/ETV6 fusion was present or not. AML with t(4;12) is morecommonin men thanin woman (the SR is 1.6). Most patients areadultswith a medianage of 60 years;only two pediatriccases have been published.The first t(4;12)-positiveAML was a “myelomegakaryocytic” leukemia(Ohyashiki,1984), but subsequentreportshave shown that most are MO, M1, or unclassifiable(UKCCG, 1992b; Haradaet al., 1995; Ma et al., 1997; Cools et al., 1999;Chauffailleet al., 2003), and it has graduallybecome apparentthat AML with t(4;12) representsa quite specific subgroup characterizedby hilineagedysplasia,1ymphoid-likemorphologyof theblasts,absentor low myeloperoxidaseactivity,basophilia,a myeloid immunophenotype with frequentaberrant expressionof the lymphoid antigenCD7, and an unfavorableprognosis.

t(4;l l)(q21;q23) Althought(4;I 1) is stronglyassociatedwith ALL, whereit is the most commonaberration rearrangingthe MLL gene (Chapter9), almost 30 AML cases with this translocationhave been reported.It was the sole change in 60%of these, with recurrentsecondarychanges including +6, -7, $8, and +19. As in ALL, the t(4;ll) in AML results in a fusion between MLL and the AF4/FMR2 family,member I gene (AFFI, previouslyAF4). Forfurtherdiscussionof this chimera,see Chapter9. AML with t(4;ll) is clearly more commonin females than in males, with an SR of 2.2. Most arepediatric,often infant,leukemias.Among the few adultpatients,the medianage has been approximately40 years.The leukemicblastsof the firstreportedAML cases with t(4;11) hada monocyticmorphology(Parkinet al., 1982),and-with a few exceptions-the BM morphologyof most subsequentlypublishedcaseshavebeenM4 orM5 (Secker-Walker et al., 1985;Johanssonet al., 1998a;Bloomfieldetal., 2002). Othercharacteristicfeaturesof t(4;11)-positive AML include leukocytosis,previouschemotherapywith DNA topoisomeraseI1 inhibitorsin 25%of thecases (mainlyin adults),anda poorprognosis.WhetherSCT improvessurvival is unclear.

Monosomy 5/de1(5q) Monosomy 5 is one of the most common numerical changes in AML, surpassedin frequencyonly by $8, -7, and $21. It is seen in 5% of all cytogeneticallyabnormal AML, almostexclusively togetherwith otherabnormalities,forexample-7,del(7q), - 17, del(l7p), and -18. In fact, only 10 AML cases with -5 as the single change have been reported.Deletionsof 5q are morecommon,occurringin 5-10% of abnormalAML. As for monosomy5 , del(5q) is most often presenttogetherwith otherchanges,again in particular whole or partiallosses of chromosomes7, 17, and 18. For this reasonandbecauseof other

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similaritiesmentionedbelow, -5 anddel(5q)areherediscussedtogether.However,del(5q) is, in contrastto monosomy 5 , relativelyoften seen as the sole anomaly;close to 200 such AMLcases havebeenreported.Of these, approximatelyone-thirdhad subcloneswith other aberrations,most frequently+8 and f21. Anothercytogeneticdifferencebetween -5 and del(5q) is the fact that monosomy 5 is rarely a secondary change to AML-specific abnormalities,whereas del(5q) is relatively common in, for example, cases with inv(3) (q21q26)/t(3;3)(q21;q26)or t(9;22)(q34;q11). The pathogeneticallyessentialmoleculargeneticconsequencesof -5 remainelusive,as indeedthey do forall monosomies.It may seem obviousthatit resultsin hemizygousloss of all genes located on chromosome5. However. with the adventof FISH, in particularthe variousmulticolormethods,it has become apparentthat -5 in AML, at least in cases with complex karyotypes, frequently is not a true monosomy. In fact, several studies have revealedchromosome5 materialelsewherein thegenome,as deletionsor-more often-as partof unbalancedtranslocationsor insertions,resultingin net loss of 5q materialonly; in addition,such investigationshave also shown that many del(5q) in fact are unbalanced translocations(Mr6zeket a]., 2002; Schoch et al., 2002; Van Limbergenet al., 2002; Bram et al., 2003). Basedon all these analysesone reallyhas to question,as Bramet al. (2003) did, whethermonosomy 5 is a commonchangein AML-it may actuallybe quiterareonce data fromall types of investigationsareassessed.The factthatmost cases with -5 in effect have del(5q) is anotherreason why these two changes are groupedtogetherin this section. The importantpathogeneticconsequenceof del(5q) is likely to be the loss of gene(s) ratherthancreationof a fusiongene, especiallyconsideringthe variableproximalanddistal breakpoints.Severalearlycytogeneticstudiesof del(5q) in Ah4Lrevealedthatthedeletions were interstitial and that 5q31 most often was a common deleted chromosomeband (Pedersenand Jensen, 1991a).Whengenes playinga criticalrole in hematopoiesis,such as those coding for colony-stimulatingfactor I receptor,granulocytemacrophagecolony stimulatingfactor,and interleukin3, were shownto be lost in MDS andAML with deletions of 5q (Huebneret al., 1985; Nienhuiset al., 1985; Le Beau et al., 1987), therewere great expectationsthat the functionaloutcome of this common myeloid-associatedaberration finally had been identified, that is, hemizygosity of genes involved in hematopoiesis allowingexpressionof a recessive mutanton the homologouschromosome5. Unfortunately, despiteextensive attemptsto delineatefurtherthe deletedregion and to identifymutant genes, progresshasbeen slow. Recently,a few genes thatmay be pathogeneticallyrelevant, at least in the "5q- syndrome,"have been identified,suggestingthathaploinsufficiencyof the transcriptionfactor early growth response 1 (EGRI) and the ribosomalprotein S14 (RPSII) genes, and loss of the catenin,alpha I gene (CTNNAI)combinedwith epigenetic silencingof theremainingallele, could be of the essence ( J o s het al., 2007; Liu et al., 2007; Ebertet al., 2008). Monosomy 5, as the sole change as well as togetherwith otherabnormalities,is more commonin men thanin women,withan SR of 1 -5.Itmainlyoccursin adultswith a medianage of 60years.Deletionsof 5q togetherwith otherchanges,on thecontrary,areequallycommon in men and women, whereasdel(5q)as the sole changeshows a clearfemalepreponderance with an SR of 1.6. Many of these may representAML secondaryto a prior5q- syndrome, which is muchmorecommonin women (Chapter6).Similarto -5, del(5q)is mainlyfoundin elderly people (medianage of 65 years).Severalstudieshave shown thatthe percentageof AMLcaseswith -5/de1(5q) increaseswithage (Schochetal., 2005a;Appelbaumetal., 2006a; Sandersonet al., 2006). In agreementwith this, thesechangesare very rarein pediatricAML (Grimwadeet al., 1998; Raimondiet al., 1999; Forestierel al., 2003).

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Monosomy 5 and del(5q) were first identified in AML in the mid-1970s (Oshimura et al., 1976;Rowley, 1976;Van Den Bergheet al., 1976).A close associationbetweenwhole or partiallosses of chromosome5, often as partof hypodiploidcomplex karyotypes,and AML was soon establishedin several studies.Subsequently,it was shown that -5/de1(5q) was significantlymorecommonin t-AMLarisingafteran initialMDS phasethanin denow AML and that these abnormalitieswere strongly associated with prior exposure to alkylatingagents, radiation,or both (Mauntzsonet al., 2002; Smith et al., 2003; Pedersen-Bjergaardet al., 2006). The AML blasts with -5/de1(5q) typicallyexpressCD2, CD7, CD13, CD14, CD15, CD18, CD33, andCD34 (Casasnovaset al., 1998; HrugQ andPorwitMacDonald,2002). Complex karyotypeswith these changes have been reportedto be particularlycommon in leukemiasof FAB types MO and M6 (Cuneo et al., 1990, 1995; Olopadeet al., 1992; Bdne et al., 2001). Soon after the identificationof -5/de1(5q) as AML-associatedaberrations,it became apparentthat they were associatedwith resistanceto chemotherapyand, hence, with an adverseprognosis (Larsonet al., 1983;FIWCL,1984b;Keatinget al., 1987). As a result, these leukemiasarenow stratifiedas high-riskin most,if not all, treatmentprotocols.Several studieshave reporteda dismal outcomeeven after intensivetreatment(Gale et al., 1995; Ferrantet al., 1997; Schochet al., 2001; Burnettet al., 2002; van der Straatenet al., 2005). Hence, new and innovativetherapeuticstrategiesare needed for this AML group.

t(5;l l)(q31 ;q23) The t(5;11) has so farbeen reported in only a handfulAML, being the sole changein all of them.It is hencea primaryAML-associatedtranslocation,althoughit shouldbe notedthata cytogeneticallyidentical,but molecularlydistinct,t(5;1 1) also has been describedin a few cases of ALL. Borkhardtet al. (2000) showedthatthe t(5;1 1) of AML resultsin a fusionbetweenMLL andARHGAP26(the Rho GTPaseactivatingprotein26 gene; formerlyGRAF);the latter gene encodes a proteininvolved in the integrin-signalingtransductionpathway.Only the MLUARHGAP26transcriptwas foundto be expressed,stronglyindicatingthatthis was the one importantin leukemogenesis.This was laterconfirmedby Panagopouloset al. (2004), who reporteda cytogeneticallycrypticins(5;1 1) thatyielded only the MLUARHGAP26 at thegenomiclevel. The few t(5;1 I )lMLL-positiveALLcases molecularlycharacterizedhave been shown to involve a differentfusion partner,namely AFF4. A brief summaryof the pathogeneticimpact of variousM U chimerasis providedlater in the I lq23 Rearrangements section. The first reportedpatientwith a t(5;11)-positive AML was an elderly woman with a previoushistoryof chemotherapywho developedAML M 1 (Hoyle et al., 1989a).However, all subsequentcases havebeen boys with denovo M4 orM5 and,withone exception,infants (Itoh et al., 1999; Borkhardtet al., 2000; Panagopouloset al., 2004; Wilda et al., 2005). Infantswith t(5;1 1)-positiveAML have respondedwell to conventionalchemotherapyor SCT. Thus,t(5;1 1) may characterizea small subgroupof infantMU-positive AML with a favorableprognosis.

t(5;l l)(q35;pl5) This translocationhas only been reported in about 10 AML cases, but since it is cytogeneticallycryptic,thereis undoubtedlyan underreporting. Severalof the cases were

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reportedas havingdel(5q) as the only cytogeneticallyidentifiablechange.AML with del (5q) as the sole change, in particularin children,may hence well harborthe cryptict(5;1 1). Jajuet al. (2001) reportedthat the t(5;l I ) rearrangesNSDl (nuclearreceptorbinding SETdomainprotein1) at 5q35 andNUP98 (nucleoporin98 kDa) at 1lpl5. Both theNDSI/ NUP98 and NUP98/NSDI transcriptswere expressedin this initial study,suggestingthat both could play a biological role. While these two transcriptswere confirmedby Brown et al. (2002), Cerveiraet al. (2003) only identifiedthe NUP98/NSDI chimera.Furthermore, Romanaet al. (2006) reporteda three-wayt(5;11;12) that resultedin NUP98/INSL>l; this varianttranslocationwould not be expectedto generatethe reciprocalfusion.The available evidence thereforestronglyindicatesthatthe NUP98hVSDl transcript,encodedby the der (1 l), is theessentialone. Theleukemogenicimpactof thevariousNUP98 chimerasis briefly summarizedin section 1l pI5 Rearrangements”below. The cytogeneticallycryptic t(5;ll) was first identifiedby Jajuet al. (1999) by HSH screening of a series of pediatricand adult MDS and AML with del(5q) as the sole aberration.The t(5;1 1) was found in threeof fourchildhoodAML (M2 and M4)with del (5q); none of the adultcases harboredthe translocation.Interestingly,the 5q deletionswere shown to involve the der(5)t(5;1 I), suggesting a complex origin of these abnormalities. Additionalstudieshave since revealed this translocationin childrenand adolescentswith cytogeneticallynormalde novo AML M 1 and M2 at an incidenceof approximately5%in both girls andboys (Brownet al., 2002; Panarelloet al., 2002). All patientshave responded poorly to treatmentand have had a shortsurvival.

t(5;17)(q35;q21) Roughly 10 AML cases with t(5;17) have been published.Most of the cases had additional changes, none of which was recurrent. Redneret al. (1996) showed thatthe t(5;17) leads to a fusion between the NPMl and RARA(retinoicacid receptor,alpha)genes, with expressionof both reciprocaltranscripts. The NPMI/RARA fusion was subsequentlyconfirmedin additionalt(5;17)-positivecases, whereas not all of them harboredthe R A W N P M I chimera (Hummel et al., 1999; Grimwadeet a]., 2000; Xu et al., 2001). It has been demonstratedthatthe t(5;17) disrupts the nucleolarlocalizationof the NPMl proteins,which insteadcolocalize with the NPMl! RARA proteins in a dispersednuclear pattern.This suggests that the chimeric protein deregulatesnot only the retinoid-signalingpathwaybut also the functionof the wild-type partnerprotein. Furthermore,NPM1RARA may influence the expression of retinoidresponsive genes in a positive or a negative manner, strongly indicatingthat aberrant transcriptionalactivation is intimatelyinvolved in the leukemogenicprocess of t(5;17)positive AML (Redneret al., 2000). The t(5;17) is equally commonin men and women but is clearlyassociatedwith young age; most reportedcases have been childrenbelow the age of 15 years. The firstt(5;17)positive AML publishedwas a pediatricAPL displayingan atypicalmorphologywithout Auer rods and respondingpoorly to all-trans retinoic acid (ATRA) treatment(Corey et al., 1994). Subsequentreports(Hummel et al., 1999; Grimwadeet al., 2000; Sainty et al., 2000; Xu et al., 2001) confirmeda strongassociationwith childhoodAPL, mainlyof the M3v type andwithoutAuerrods.These studieshave also shownthatthe t(5;17) is very rarein APL, comprisingless than I % of suchcases, andthat,in contrastto the initialreport, responseto ATRA is usually good.

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65

t(6;9)(~22;qW Thet(6;9), frequentlyreportedwitha breakpointin 6p23 butnow knownto involve the DEK gene mappingto 6p22, occurs in 0.5% of all cytogeneticallyabnormalAML, most often (80%)as the sole change. The only recurrentsecondarychangeshave been +8, del(l2p), and f13. From the involvement of the 9q34 breakpoint,it was initially thoughtthat the t(6;9) involvedABLl. However,Westbrooket al. ( 1985) showedthatABLl was not translocated from chromosome 9. Subsequently,von Lindernet al. (1990) identifiedclustering of breakswithin a small region 360 kb downstreamof the ABLI locus, involving the gene coding for nucleoporin 214kDa (NUP214, previously known as CAN), an essential componentof the nuclearpore complex (NPC) at the nuclearenvelope and requiredfor propernucleocytoplasmic transport,akin to N U B 8 (see section 1 l p l 5 Rearrangements”).Shortly afterward,the DEK gene at 6p22 was identifiedand shown to fuse to NUP214, yielding a DEWNUP214 transcript(von Lindern et al., 1992). The DEK proteinis a majorcomponentof the chromatinthatis able to modify the DNA structureby introducingsupercoils (Kappes et al., 2004). Furtherstudies of the chimeric protein revealed that it is localized exclusively to the nucleus and that there is a substantial increaseof global protein synthesisin cells expressingDEK/NUF’214.This is restricted to myeloid cells and caused by increasedtranslationratherthan dysregulatedtranscription (Fornerodet al., 1995; Boer et al., 1997a; Ageberg et aI., 2008). However, much remains to be elucidated regarding the leukemogenic impact of DEWNUP214. In contrast to what is seen in most AML-associated translocations, internal tandem duplications(ITD) of the FMS-relatedtyrosine kinase 3 (FLT3) gene are very common in t(6;9)-positive AML, suggesting that DEUNUP214 and FLT3 ITD cooperatein the leukemogenesisof t(6;9)-positive AML (Oyarzoet al., 2004; Gargonet al., 2005; Slovak et al., 2006). The t(6;9) does not display any gender-relatedfrequencybias, but mainly occurs in childrenoryoungeradults,witha medianage of only 30 years.Thefirstt(6;9)-positiveAML was reportedby Rowley and Potter(1976), and with the descriptionof several additional cases in the early 1980s, this translocationwas firmly establishedas a primaryAMLassociatedabnormality.The t(6;9) is rarein AML. Soekarmanet al. (1992) examinedmore than 150 MDS and AML cases and detectedrearrangements of DEK andNUP214 in only one. No abnormalitiesof these two genes were detected in 20 additionalcases with cytogenetic aberrationsthat, based on the 6p and 9q breakpointpositions, might have representedvarianttranslocations. Severalinvestigatorshave identifiedmorphologicandclinical featuresthatcharacterize this raregenetic subgroup(Pearsonet al., 1985; Oyarzoet al., 2004; Garsonet al., 2005; Slovak et al., 2006). The majorityof cases are de nova AML,most frequentlyM2, M4, or M 1. Auerrodsarepresentin a substantialproportionof thecases andthe blastsaretypically positive for CD9, CD13, CD15, CD33, CD34, CD38, CD45, CDI17, and HLA-DR. Trilineagedysplasia is common, and so is BM basophilia,with the latterbeing present in close to 50%.The responseto chemotherapyis often poor, and survival,at least after conventionaltreatment,has been reportedto be dismal.Thus,t(6;9) is now includedin the poorcytogeneticriskgroupin most treatmentprotocols.Encouragingresults-albeit based on few and small patient series-have been obtained after allogeneic SCT (Boer et al., 1997b;Gargonet al., 2005; Slovak et al., 2006).

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t(6;ll)(q27;q23) Although the t(6;I 1) is seen in less than 0.5%of all cytogeneticallyabnormalAML, it is neverthelessthe fourthmost common 1 lq23 translocationin this disease;t(9:1 I)(p21;q23), lOplUl lq23 rearrangements,and t( 11;19)(q23;p13)are more common. It is the sole changein 90%,with the most frequentsecondaryaberrationsbeing gain of theder(6)t(6;1I ) and trisomy for chromosomes8, 19, and 21. Prasadetal. (1993) showedthatMLLwasfused toMLLT4(originallyAF6)asaresultofthe t(6;1 1). Thatthe MLUMLLT4transcript,encoded by the der(1 l)t(6;1 I), was importantfor leukemogenesiswas suggestedby Cherifet al. (1994), who identifiedadeletioninvolvingthe 3’ partof the M U gene in an AML with t(6;ll). It was laterconfirmedthatthe reciprocal fusion gene was not expressedin t(6;I 1)-positivecases (Tanabeet al., 1996).The functional outcomeof the additionalder(6)t(6:1 1) sometimesseen hence does not involve increased expressionof the reciprocalMLLT4MLL chimera.In fact, duplicationof the “noncritical“ derivative(i.e., the one not coding for the leukemogenic fusion) has been shown to be commoninseveralMLLtranslocations,suchas+der(4)t(4;1l)(q21;q23)and+der(9)t(9;1 I ) (p21;q23),as well as in otheraberrations, forexample+der(8)t(8;2l)(q22;q22)and+der( 17) t( 15: 17)(q22;q21),stronglyindicatingthat the genomic imbalance,ratherthan overexpression of reciprocaltranscripts,is pathogeneticallyimportant(Johanssonet al., 1998b). Thet(6;1 1 ) is equallycommonin womenandmen andmainlyoccursin young adults;the medianage is about40 years.The aberrationwas firstdescribedin AML M4 andM5 in the early 1980s (Hagemeijeret al., 1981; Yunis et al., 1981),but only a few additionalt(6;ll)positive cases were reported during that decade, probably because of difficulties in identifying it. AML with del(l I)(q23) as the sole change may harborthe t(6;l l), as shown by FISH analyses of “terminal”deletions of 1 lq23 (Derr6et al., 1990; Kobayashi et al., 1993a). Severalstudieshave identifiedmorphologicand clinical featuresassociated with t(6;11)-positive AML (Martineauet al., 1998; Bloomfield et al., 2002; Blum et al., 2004; Meyeret al., 2006). It has been shown that althought(6;I 1) is rare,it actually comprises5-10% of all AML with MLL rearrangements, being more common in African Americanthan in Caucasianpatientsin the United States. The vast majorityof t(6;ll)positive AML are morphologicallycharacterizedas M4 or M5, with the blasts typically expressingCD13, CD33, CD34, and HLA-DR. In contrastto many otherMLL translocations, the t(6;ll) is mainly found in de novo A m . Most studies have stressed a poor responseto chemotherapyand hence a dismal prognosisfor patientswith t(6;I 1)-positive AML,with an estimatedprobabilityof 2-yearsurvivalof only 10%.Thepooroutcomemay, however, be overcome by allogeneic SCT (Takatsukiet al., 2002; Blum et al., 2004).

Monosomy 7/de1(7q) Next to trisomy8, monosomy7 is the mostcommonnumericalchromosomeabnormalityin AML, being found together with other changes, mainly -5, dei(5q), and -17, in approximately10%of all cytogenetically abnormalAML. Monosomy 7 is frequently (5%)the sole change.Deletionsof 7q arealso common(5%)andmostoftenpresenttogether with otheraberrations,in particularlosses involving chromosomes5 and 17. However,in contrastto -7, only I % of karyotypicallyaberrantAML have del(7q)as the sole anomaly. Another cytogenetic difference between -7 and del(7q) is the fact that AML with monosomy7 as an isolated change rarelyharborsubclones with other aberrations.AML with del(7q) as the sole aberrationdisplay subclones,or occasionallyunrelatedclones, in almost one third of the cases. Often +8 is the otherchange.

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Monosomy 7 as well as del(7q) are common secondarychanges in AML with specific abnormalities,for example-7 is seen in 50%of cases withinv(3)(q2lq26)/t(3;3)(q21;q26) and 35% of t(2;3)(pll-23;923-28). In fact, there is a clear association between 3q26 rearrangementslEVIIexpression and loss of chromosome 7. As regards del(7q), this aberrationis seen in 15%of t(3;12)(q26;p13),in 8% of t(3;21)(q26;q22),and in 5%of AML with inv( 16)(p13q22).It shouldbe emphasizedthatthe presenceof del(7q)together with inv(16) does not confer a poor prognosis (see inv(l6)(pl3q22)/t(16;16)(p13;q22) section below). The pathogenetically importantmolecular genetic consequence of monosomy 7 is unknown.As for monosomy5, it has been shownthat -7 in AML.with complexkaryotypes is often not a truewhole chromosomeloss. MulticolorFISH studieshave identifiedchromosome 7 materialon other chromosomes,for example on ring chromosomesand markers (Gibbonset al., 1994; Mr6zeket al., 2002; Schochet al., 2002; Van Limbergenet al., 2002). Most moleculargenetic studiesof del(7q) have focused on identifyingmutatedtumor suppressorgenes on the normal homologue, which map within the commonly deleted region of 7q. Several deleted regions, all interstitialand mainly involving 7q22 and 7q32-33, have been implicated (Kere et al., 1989; Le Beau et al., 1996; Dohner et al., 1998; Liang et al., 1998; Tosi et al., 1999). As there is a markedheterogeneity of thebreakpointsat 7q, it has been concludedthatthe loss of severalgenes ratherthanof a single tumor suppressorgene is the pathogeneticallyimportantoutcome. However,the targetgenes remainelusive. AML with -7 or del(7q) were initially reported in the 1970s (Petit et al., 1973; Rowley, 1973a), and whole or partiallosses of chromosome7 were quickly established as nonrandomAML-associatedabnormalities.Monosomy7 is morecommonin men thanin women, with an SR of 1.4 when foundtogetherwith otherchangesand 1.9 when seen as the sole change. Also del(7q) is more frequentin men (SR 1.2). The median age of AML patientswith -7/de1(7q) is higher(55 years)when otheraberrationsarepresentthanwhen found alone (45 years), with the frequencies of AML with -7/de1(7q) in complex karyotypesincreasingwith age, similar to chromosome5 losses (Schoch et al., 2005a; Appelbaumet al., 2006a; Sandersonet al., 2006). In contrastto the latter,-7/de1(7q) is also commonin pediatricAML, occurringin 5%of the cases (Grimwadeet al., 1998;Raimondi et al., 1999; Forestieret al., 2003). There is a clear association between AML with -7/de1(7q) and previous genotoxic treatment,in particularwith alkylatorsand/orradiotherapy(Mauritzsonet al., 2002; Smith et al., 2003; Pedersen-Bjergaard et al., 2006). Both these and de nova cases are often morphologicallyunclassifiable;the most common FAB types among the classified cases are,in decreasingfrequencyorder,M6, MO, MI, and M7 (Cuneoet al., 1990,1995;Olopade et al., 1992; Btn6 et al., 2001; Dastugueet al., 2002). The blasts aretypicallypositive for CD7, CD13, CD15, CDl8, CD33, andCD34 (Casasnovaset al., 1998;HruGk and PorwitMacDonald,2002). As previouslymentionedandas reviewedby Miilleret al. (2002), there is an unaccounted-forassociationbetween the presenceof monosomy 7, with or without 3q21q26 aberrations,and diabetes insipidus. That -7/deI(7q) has an adverse prognostic impact was realized in the early 1980s (Borgstromet al., 1980;Larsonet al., 1983), and it is today well recognized that AML with these changes display a poor response to chemotherapyand, hence, are associated with a dismal outcome (Grimwadeet al., 1998; Slovak et al., 2000; Byrd et al., 2002; Haferlach et al., 2004; Hasle et al., 2007). It is questionable whether more intensive chemotherapyor allogeneic SCT improves survivalof adult patients (Gale et al., 1995;

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7

11

FIGURE5.7 The t(7;l l)(p15;p15)is associatedwith AML M2 or M4,trilineagedysplasia,and Auer rods. Arrows indicate breakpoints.

Schoch et al., 2001 ;Burnettet al., 2002; van der Straatenet al., 2005). However,SCT has been shown to be of value in pediatric AML with monosomy 7 (Trobaugh-Lotrario et al., 2005). t(7;11)(p15;p15) Almost 50 AML cases with t(7;l I ) (Fig. 5.7) have been published,constitutingthe most common translocationinvolving I lp15/NUP98. The translocationis the sole change in approximately80%of cases,with 8 as theonly recurrentsecondarychangereportedto date. Borrowet a). (1996a) and Nakamuraet al. (1996) showed that the t(7;11) resultsin a fusion between the NUP98 gene at 1 lp15 and the HOXA9 gene at 7 ~ 1 5The . NUP98/ HOXA9, transcribedfrom the der(1 I), was suggested to be the leukemogenictranscript because it retained importantstructuralmotifs of the two genes, namely the HOXA9 homeodomain and the " 9 8 repeats that function as docking sites during nuclear transport.Furtherstudies not only confirmedthis chimera in t(7;1 ])-positive AML but also identifiedfusions with otherHOXA members,that is, HOXAl I and HOXAI3 (Hatano et al., 1999; Kwong and Pang, 1999; Fujino et al., 2002; Taketaniet al., 2002). The leukemogenic impact of the various NUP98 chimeras is briefly summarizedin section "1 I pl5 Rearrangements" below. The t(7;l I ) is slightly morecommonin men than in women with an SR of I .3. It is very rarein children,occurringmainly in young adultswith a medianage of approximately40 years.The t(7;11) was firstidentifiedin a Japanesepatientwith AML by Ohyashiki(1984), and since then it has become apparentthat this translocationis clearly more common in AML patientsof Orientalorigin. In fact, 25% of all publishedcases have been from Asia, particularlyJapanand China,a higherprevalencethanfor AML cases in general( ~ 1 5 % ) . Nevertheless,it shouldbe emphasizedthatt(7;1 I ) is a rareAML-associatedaberrationeven in these countries,being identifiedin only 1 % of adultChineseAML patients(Kwongand Pang, 1999). With a few exceptions,all publishedt(7;I 1)-positivecases have been de n ow AMLandmost havebeen morphologicallycharacterizedas M2 or M4,oftenwith Auerrods andtrilineagedysplasia(Sat0et al., 1987;Huanget al., 1997; Kwong and Pang, 1999).The prognosisafterconventionalchemotherapyhas been reportedto be poor, andwhetherSCT may improvethe outcome is unclear.

+

t(7;12)(q36;p13) Approximately20 AML cases anda few ALL with t(7;12)(q36;p13)havebeen published.In addition,a few caseswitht(7;12)(q32;pl3),thatis, with a moreproximal7q breakpoint,have

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

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also been reported.Many t(7;12)(q36;p13)-positivecases may be undetectedas the translocationis verydifficultto identifycytogenetically(Hagemeijeret al., 1981;Heimetal., I987b; Raimondi et al., 1999). The t(7;12) is rarely the sole cytogenetic change; with a few exceptions,also Visomy 19 is present.Anotherrelativelycommon secondaryaberration is trisomy8. Thus,infantAMLwith 19andor 8 shouldbe testedforthepresenceof t(7;12). Tosi et al. (1 998) and Wlodarskaet al. (1998) showed thatthe t(7;12), involvingeither 7q32 or 7q36, rearrangesthe ETV6gene at 12p13, and Beverlooet al. (2001) subsequently identifieda fusion between the motorneuronand pancreashomeobox 1 (MNXJ, initially HLXB9) gene at 7q36 and ETV6, with expression only of the MNXUETV6 chimera. However,several t(7;12)-positivecases have 7q36 breakpointsthatdo not map within the MNXl gene and do not resultin MiWUEW6. It has thereforebeen questionedwhethera fusion gene is the importantresultof the translocation(Tosi et al., 2000,2003; Simmons et al., 2002). AlthoughadditionalMNXI/ETV6-positivecases were reportedby von Bergh et al. (2006), they identifiedectopic expressionof the MNXl gene in all t(7; I2)-positive cases, with or withoutthe MNXUETV6fusion.Thus,aberrantexpressionof MNXl may be the functionallyimportantoutcome of the t(7;12)(q36;p13). The t(7;12) is slightly morecommonin girls than in boys, with an SR of 1.3. Althougha few infantALL cases with this translocationhave been reported(Tosi el al., 2000, 2003; Slateret al., 200 I ;von Berghet al., 2006), it is almostexclusively foundin infantAML. It is presentin 20-30% of infantAML, makingit the secondmost commonrearrangement after 1 1 q23 changes in this age group. Although the morphology of t(7;12)-positive AML is variable,a significantproportionof the cases have been poorly differentiated,that is, MO or MI. The outcome,at least afterconventionalchemotherapy,has been very poor, with a 3-year event-freesurvivalof 0%.

+

+

Trisomy 8 Trisomy8 is the most commonchromosomalchangein AML, being the sole changein 5% of all cytogeneticallyabnormalcases and occurringtogetherwith otheraberrationsin an additional10%.As a secondarychange, +8 is particularlyfrequent(210%)in AML with der(1;7)(qlO;plO),t(3;21)(q26;q22),t(7;12)(q36;pl3),t(9;1 l)(p21;q23),t(9;22)(q34;qlI), t(l1;17)(q23;q21), t(11;19)(q23;p13.1),t( 15;17)(q22;q21),and inv(l6)(p13q22). The essential functional/moleculargenetic consequences of +8 remain unknown. Possible mechanismsinclude globalgene expressionchanges, deregulationof imprinted loci, and duplicationof rearrangedor mutatedgenes presenton the extrachromosome8. However,asrecentlyreviewedby PaulssonandJohansson(2007), investigationsaddressing these issues have so far been unfruitful.Genes on chromosome8 areoften overexpressed, butalternativegenes have been shownto be up-ordownregulatedin differentstudies.Also, and in contrast to what is seen in AML with well-known primarytranslocationsand inversions,there does not seem to be a stronggene expressionsignatureassociatedwith +8. Furthermore,no genes on chromosome8 have been shown to be imprinted,no AML with acquiredsegmentaluniparentaldisomy (UPD) involvingchromosome8 loci has been reported,andthe originof the additionalchromosome8 may be maternalas well as paternal; all thesefactorsstronglyargueagainstimprintingbeingof pathogeneticimportance.Finally, no gene on chromosome8 has been shown to be mutatedor rearrangedand duplicatedin AML with +8. Thus, the pathogeneticimplicationsof +8 are far from clarified. There is ample evidence that trisomy 8 is not sufficient for leukemogenesis. First, althoughindividualswith a constitutional+8 mosaicismhave an increasedrisk of AML,

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only a minoritydevelop this disease, andoften aftera long latencyperiod(Welborn,2004). Second, there is as yet no clearly increasedrisk of AML in CML patientswith trisomy 8-positive/t(9;22)-negativeclones emerging after treatmentwith imatinib (Chapter7). Third,Schoch et al. (2005b) reportedthat the discriminatinggene expressionpatternof AML with isolated +8 did not dependon the upregulationof chromosome8 genes alone, concluding that additionalgenetic changes may be present. In fact, array-basedCGH analyses have revealed several cryptic chromosome changes in AML with +8 as the seemingly sole change (Paulssonet al., 2006). Trisomy8 as the sole anomalyis equallycommonin males and females. It occursin all age groupsbutwith the incidenceincreasingwith age;the medianis 50 years.Although +8 may be found in all morphologicsubtypesof AML, it has been reportedto be particularly frequentin MI, M2, M4, and M5 with a higher incidence in M5a than in M5b (Schoch et al., 1997; Byrdet al., 1998;Elliottet al., 2002; Faraget al., 2002; Haferlachet al., 2002; Wolman et al., 2002). Trisomy 8-positive AML do not seem to display any specific immunophenotypicfeatures(Hru5kand Porwit-MacDonald,2002) but may differ from othercytogeneticallyabnormalAML by having a lower expressionof CD34 and a higher expressionof CD36 (Casasnovaset al., 1998; Pereaet al., 2005). Trisomy8 as an isolatedchangeis rarelyassociatedwith previousgenotoxicexposure.It is significantlymorecommonin de now AML thanin t-AML(Mauritzsonet al., 2002). As regardsthe prognosticimpactof +8, severalstudieshave reportedit to be associatedwith an intermediateprognosisin AML (Dastugueet al., 1995; Schochet al., 1997; Grimwade et al., 1998; Wolman et al., 2002; Jaff et al., 2007). However, some investigatorshave identifieda pooreroutcomethan is usually seen in the intermediategroup,suggestingthat SCTshouldbe considered,at least in youngerpatients(Byrdet al., 1998;Elliottet al., 2002; Faraget al., 2002; Schaich et al., 2007). t(8;16)(pll ;p13) Approximately70 AML cases with t( 8;16) (Fig. 5.8) have been reported,comprising0.5% of all cytogeneticallyaberrantcases, with the translocationbeing the sole changein 60%. The most common secondaryaberrationsare +8, +13, and +21. Borrowet al. (1996b) showedthatt(8; 16)disruptsthe MYST histoneacetyltransferase 3 gene (MYST3, previouslyMOZ) on 8pl I and the CREB binding proteingene (CREBBP, formerlyCBP)on 16p13resultingin theirfusion, with only theMYST3KREBBP transcript being in-frame.FISH and Southernblot analysessoon confirmedgenomicrearrangements

8

16

FIGURE 5.8 The t(8;16)(pl l;p13) is strongly associated with AML M4 or M5 and hemophagocytosis. Arrows indicate breakpoints.

CHARACTERISTICCHROMOSOME ABNORMALITIESIN AML

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of these two genes in additional cases (Giles et al., 1997). RT-PCR studies showing amplificationof both the MYST3/CREBBP and the CREBBP/MYST3 chimeras have subsequentlybeen reported(Panagopouloset al., 2000; Schmidt et al., 2004). In some instances,however,the lattertranscriptwas not amplified,stronglysuggestingthatMYST3/ CREBBP is the leukemogenicone. Furtheranalysesof MYST3ICREBBP haverevealedthat this chimera inhibits RUNX 1 -mediated transcription,indicating that MYST3ICREBBP induces leukemia by antagonizingthe function of the RUNXI complex (Kitabayashi et al., 200 1). Morerecently,gene expressionprofilingof t(8;16)-positiveAML has revealed thatthey clusterand are associatedwith a specific patternof HOXgene expression(Cam& et al., 2006), again implicatingderegulatedtranscriptionas a pathogeneticallyimportant outcomeof the t(8;16). The t(8;16) is more common in females than in males (SR 1.7). It occurs in infants, childrenand,mainlyyounger,adultswith a medianage of 45 years.An associationbetween t(8; 16) and monocytic/monoblasticdifferentiation,often with extensive erythrophagocytosis, was stressedin the initialreportsof this translocation(Bernsteinet al., 1987;Heim et al., 1987a).Subsequentlargerseries of t(8;16)-positivecases have clearlyshown thatthey aremostoften M5,occasionallyM4,hemophagocytosisis presentin 75%of thecases, EML anddisseminatedintravascular coagulation(DIC)arerelativelycommon,andone quarterof the patientshave receivedpreviouschemotherapy,mainly includingan anthracycline(or derivative)targetingDNA topoisomeraseI1 (Hanslipet al., 1992; Quesnel et al., 1993; Velloso et al., 1996; Block et al., 2002; Mauritzsonet al., 2002). A very poor prognosis,at least afterconventionalchemotherapy,has been repeatedlyreported. t(8;21)(q22;q22)

The t(8;21) (Fig. 5.9) is foundin -7% of all cytogeneticallyabnormalAML, makingit the most frequenttranslocationand the fourthmost commonaberrationoverall(after f 8 , -7, and deletion of 5q) in this disease. It is the sole change in 40% of cases; secondary aberrationsinclude,in decreasingfrequencyorder,-Y, -X (femalesonly),del(9q), +8, del (7q), +der(21)t(8;21), +4, and +15. Although the t(8;2 1) is easy to recognize cytogenetically, rearrangementsbetween 8q22 and 2 1 q22 may be maskedwithincomplex karyotypes,or may even be the resultof cryptic insertions.Complex translocationsinvolving 8q22,21q22, and anotherchromosome band comprise almost 5% of the cases (GFCH,1990). Some of these may not be interpretedas variantsof t(8;21). Approximately8%of the cases have been reportedto harborhiddeninsertions(Harrisonet al., 1999; Gamerdingeret al., 2003). Thus,an AML

a

21

FIGURE 5.9 The t(8:2 l)(q22;q22) is strongly associated with AML M2, granulocytic dysplasia, and Auer rods. Arrows indicate breakpoints.

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with morphologic, immunophenotypic,or clinical features strongly suggesting the presenceof a t(8;21) not observedby chromosomebandinganalysis shouldbe analyzed by FISH or RT-PCR. Miyoshi et al. (1991) showed that the 21q22 breakpointsin t(8;21) clusteredwithin a limitedregion of RUNXI, and shortlyafterward,Ericksonet al. (1992) identifieda fusion transcriptconsisting of RUNXI and RUNXITI; the latter gene, which usually is not expressed in hematopoieticcells, was initially denoted “eight twenty-one” (ETO) or “myeloid translocationgene at chromosome8” (MTG8) by Ericksonet al. (1992) and Kozu et al. ( 1993),respectively.Interestingly,persistenceof theRUNXl/RUNXl TI chimera was noted in patients in long-term remission after chemotherapyor autologous SCT (Nuciforaet al., 1993b; Kusec et al.. 1994). These findings stronglysuggestedthat the t (8;21) was not sufficient for leukemogenesis.This has since been verified based on, for example,in uterooriginof the fusion with a long latencyperiodbeforeovertAML in some cases (Wiemelset al., 2002) andthe fact thattransgenicmice remainhealthywith a normal hematopoiesisunless exposed to a strong DNA-alkylatingmutagen(Yuan et al., 200 1). Additionalevents are thereforerequiredfor leukemogenesisand,as recentlyreviewed by Petersonet al. (2007), severalsuch changeshave now been identified,for example,FLT3, KIT,and NRAS mutations.Numerousstudieshave addressedthecellularand leukemogenic effects of RUNXURUNX1TI. They have revealedthatthis chimericprotein,in contrastto normalRUNX1, acts as a repressor,downregulatingits targetgenes involved in granulocytic differentiationand repressingseveralimportanthematopoietictranscriptionfactors, and that it perturbshematopoieticstem cell homeostasis(Elagib and Goldfarb,2007). The translocationbetweenchromosomes8 and21 was firstreportedby Rowley (1973b) and soon confirmedby othergroups.To date, close to 1500 AML cases with t(8;2I ) have been published.Thereis a male preponderancewith an SR of 1.5. The t(8;21) is seen in all age groupsbutis particularlycommonin childrenandyoung adults;the medianage is only 30 years. In the review by Johanssonet al. ( 1991) on geographicheterogeneityof neoplasiaassociatedabnormalities,this translocationwas found to be significantlymorefrequentin patientsfromAsia as comparedto those fromEuropeandthe UnitedStates.Morerecently, Sekereset al. (2004) reportedthat the t(8;21) is morecommon in AfricanAmericansthan among Caucasiansin the United States. Whetherthis reflects genetic or environmental factors,or is even a fortuitousfinding, is presently unknown. Morphologically,the vast majorityof t(8;21)-positiveAML are M2 - only occasional cases havebeen classifiedas MI or,morerarely,M4. In some instances,the blastpercentage is below the cut-offfor AML,somethingthatpriorto the presentWHOclassificationwould have resultedin a diagnosisof MDS. Typically,the BM displaysAuerrods anddysplastic featuresof the granulocytes;in some cases dyserythropoiesisandordysmegakaryopoiesis is also seen, but trilineagedysplasiais rare.A certaindegree of eosinophiliais common. Taken together,the t(8;21) subgrouphas distinctmorphologicfeaturesthat distinguishit fromothertypes of AML (Swirskyet al., 1984;Davey et al., 1989;Haferlachet al., 1996a; Billstromet al., 1997;Nakamura et al., 1997). The immunophenotype is also characteristic, with positivityfor HLA-DR,MPO, CD13, CD15, CD18, CD34, andCDI 17 but negativity for CD2, CD4, CD7, CDI 1, CD14, and CD33; aberrantexpressionof the B-cell antigen CD19 and the NK-cell antigenCD56 is commonandnoteworthy(Hurwitzel al., 1992; Kita et al., 1992; Casasnovas et al., 1998; Ferrara et al., 1998; HruGk and PorwitMacDonald,2002). Froma clinicalpointof view, it is importantto be awareof the factthatEML,principally in the mastoid and orbitalcavities or paraspinally,is seen in 10-25% of patients,at the

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

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time of diagnosis or at relapse (Tallmanet al., 1993; Billstrom et al., 1997). In some instances,the EML occurs before overt BM involvement, and such cases may be misdiagnosedas lymphomas.Most t(8;21)-positiveAML arede nuvu leukemias;only 5% are treatment-related, arising mainly after treatmentwith topoisomeraseI1 poisons-anthracyclines as well as epipodophyllotoxins(Quesnel et al., 1993; Mauritzsonet al., 2002; Slovak et al., 2002). Patientswith t(8;2])-positive AML usually achieve complete remission afterconventional chemotherapyand have been shown to respond particularlywell to high-dose cytarabinetreatment.The t(8;21) is henceassociatedwith a favorableprognosis(Haferlach et al., 1996a;Grimwadeet al., 1998; Byrd et al., 1999; Nishii et al., 2003). However,some additionalfeatureshave repeatedlybeen associatedwith worse prognosis,namely leukocytosis, EML, and KIT mutations (O’Brien et al., 1989; Billstrom et al., 1997; Byrd et al., 1997; Nguyen et al., 2002; Schlenk et al., 2004; Paschkaet al., 2006; Schnittger et al., 2006; Shimadaet al., 2006).

t(9;l l)(p21 ;q23) Approximately350 AML cases with t(9;I 1 ) (Fig. 5. lo), with breakpointsin either9p2 1 or 9p22, havebeen reported.BecausetheM U T 3gene (see below) is now known to be located in the formerband,thatbreakpointdesignationis the one used here.The t(9;I 1 ) is the most frequentchromosomechangeinvolving 1 lq23/MLLin AML and the fourthmost common balancedaberrationin this disease, aftert(8;2l)(q22;q22), t( 15;I7)(q22;q21 ), and inv(16) (p I3q22),constituting2%of all cytogeneticallyabnormalcases. It is thesole changein twothirdsof these. Trisomy 8, the most common secondaryabnormality,is found in almost 20%;otherrelativelyfrequentadditionalchangesincludetrisomiesof chromosomes6,19, and 21. The t(9; 1 I ) is a subtletranslocationthatmay easily be overlookedin cases with inferior chromosomemorphology.It is thereforewise to scrutinizedistal9p and 1 I q in monoblastic leukemiawith an apparentlynormalkaryotype(NK)or with +8 as the sole change. In addition, the MLuMLLT3fusion (see below) may also arise through more complex mechanisms,such as three-way translocationsand insertions;the lattermay be difficult/ impossibleto identifywith chromosomebandinganalysis(Shagoet al., 2004). Thus,the use

1 49

11

FIGURE 5.10 The t(9;ll )(p21;q23) is strongly associated with AML M5 and with t-AML. Arrows indicate breakpoints.

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of FISH or RT-PCRanalysisis advisablein cases where the translocationis suspectedfor morphologic,immunophenotypicor clinical reasons. Iidaet al. ( 1993) and Nakamuraet al. ( 1993) reportedthat t(9;1I ) fuses the MLL gene with MLLT3 (previouslyAF9 and LTG9),which was shown to sharesequence homology with MLLTl involved in t( 1I; I9)(q23;p13.3) (see separatesection below). In a seminal studyby Corralet al. (1996), who used homologousrecombinationin embryonalstem cells to createchimericmice with the M L u M u T 3 fusion,it was shownthatthe gene fusion was oncogenic, leading to AML. However,as a result of the long latency periodbefore overt disease, they concludedthatother,secondarymutationswere necessaryfor leukemogenesis; FLT3 ITD is one likely such cooperatingaberration(Stubbset al., 2008). A brief summaryof the pathogeneticimpact of various M U fusions in AML is providedin the 1lq23 Rearrangementssection. Thet(9;I 1) is equallycommonin femalesandmales. It mainlyoccursin infants,children and young adults,giving a median age of only 20 years. Thus, the frequencyof t(9;I 1) is higher(10%) in pediatricAML (Raimondiet al., 1999;Forestieret al., 2003) than in adult AML (1-2%) (Mr6zeket al., 1997; Mauritzsonet al., 2002; Schochet al., 2003). However, the t(9;11) constitutesone third of all MLL rearrangementsin both age groups (Meyer et al., 2006). The t(9;lI ) was firstreportedas a characteristictranslocationin AML by Hagemeijer et al. (1982). Theyemphasizedits strongassociationwith monoblasticleukemia,which was quicklyconfirmedin subsequentstudies.Althought(9;11)predominantlyoccursin M5, it is also seen in othersubtypes,suchas M4 or M 1. It can also be found,albeitrarely,in ALL and MDS (Swansburyet al., 1998). The t(9;11 )-positive blastsaretypicallypositive for CD 1 I, CD13, CD15, and CD33 but less often express CD14, CD34, or lymphoid markers (Casasnovaset al., 1998; Swansburyet al., 1998). EML, mainly in the skin but also in the abdomen,orbit, and thorax,is common (Johanssonet al., 2000; Parket al., 2001). Treatment-related AML with t(9;ll) were reportedby Dewald et al. (1983) and Weh et al. (1986). It was soon realizedthatthis abnormalitywas frequently(35%)associatedwith priorchemotherapy,oftenincludingetoposide,a drugknownto inhibitDNA topoisomerase 11 (Ratain et al., 1987; h i et al., 1989; Pedersen-Bjergaard et al., 1990; Bloomfield et al., 2002). Actually, the prevalenceof t(9;1 1) is significantlyhigher in t-AML than in de nova AML (Mauritzsonet al., 2002). In contrastto most translocationsaffectingthe MLL gene, the t(9;1I ) is not associated with a particularlypoorprognosis.Several studiesof pediatrict(9;1 1)-positiveAML have revealeda very favorableoutcome,oftenbetterthanthe one observedin AML with t(8;21), t(15;17) or inv(l6) (Kalwinsky et al., 1990; Martinez-Climentet al., 1995; Rubnitz et al., 2002; Lie et al., 2003). In adult AML, the t(9;11) has also been correlatedwith superiorsurvival, at least comparedto other abnormalitiesinvolving I lq23 (Mr6zeket al., 1997).Forthisreason, I lq23 rearrangements in adultAML arenow often dichotomized into t(9;ll) andnon-t(9;I l), with the formerbeing includedin the intermediateprognostic groupand the latterin the high-riskgroup.

W9q) Deletionsof thelong arm of chromosome9 arerelativelycommonin AML,occurringin 3% of all cytogeneticallyabnormalcases; of these, it is the sole abnormalityin roughlyonethird.As a secondarychange, it is particularlyfrequent(10%)in t(8;21)-positiveAML.

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

75

Althoughdel(9q) is stronglyassociatedwith AML, it has been reportedas a single anomaly also in a few MDS and MPD cases. Mecucciet al. ( 1984), the firstto investigatedel(9q)in detail,concludedthatthe deletion was interstitialand thatthe breakpointswere variable.However,Sreekantaiahet al. (1 989) subsequentlyreporteda clusteringof breaksin 9q21-22, suggestingthat genes of importance in leukemogenesiswere located in these bands. Furthercytogenetic and molecular genetic characterizationof del(9q) confirmed this position for the deletion (Peniket et al., 2005; Sweetserel al., 2005). The lattergroupidentifieda commonlydeletedregion of less than 2.4 Mb within 9q21 and identifieddownregulationof several genes here. As none of the genes were mutated, they suggested that haploinsufficiencymight be the essential leukemogenicmechanism. The first AML with del(9q)as the sole changewas reportedby Sasakiet al. (1976), with additionalcases beingreportedin the early 1980s. Due to the rarityof del(9q)as an isolated aberration,studiesof its clinical and prognosticimplicationshave been few. Based on all publishedcases, del(9q) is somewhatmore common in men than in women (SR 1.2). It mainlyoccursin adults;the medianage is roughly50 years.None of the publishedcases had a previous history of chemotherapyor radiotherapy.Morphologically, most are M2 followed by M1 and M4. Many display a markedvariationin size and nucleus-to-cell ratioof the blasts,containinga single long and slenderAuer rod, erythroiddysplasia,and granulocyticlineage vacuolation(Hoyle et al., 1987; Peniketet al., 2005). The immunophenotypicfeatures,admittedlybasedon only a few cases, includepositivityfor HLA-DR, CD15, CD33, and CD34 as well as aberrantexpressionof the T-cell antigen CD7(Tien et al., 1995;Ferraraet al., 1996).The few largerpatientseriesin whichtheprognosticimpact of del(9q) as the sole change has been investigated all showed an overall survival of approximately50%(Grimwadeet al., 1998; Byrd et al., 2002; Peniketet al., 2005). Such cases arenow includedin the intermediatecytogeneticrisk groupin most AML, protocols. Interestingly,CEBPA mutations,which are associated with a favorableprognosis (Preudhommeet al., 2002), have been identified in close to 50%of del(9q)-positiveAML (Frohlinget al., 2005). This is probablyone reasonfor the relativelyfavorableoutcome,at least within the intermediategroup, of del(9q)-positiveAML.

Apart from being characteristicfor CML and quite common in adult ALL (Chapters7 and 9), the Philadelphia-producing t(9;22) also occurs in AML in 1%of all karyotypically abnormalcases. It is the sole anomaly in roughly 40%. with the most common secondarychanges being, in decreasingfrequencyorder, $8, -7, +19, and +der(22) t(9;22). These aberrationsare also frequentin CML BC. The question thereforeoften arises whethera t(9;22)-positiveAML representsCML in myeloid BC or whether it is a de novo AML. There aresome genetic and clinical differencesbetween CML BC and de now AML with t(9;22) that may help discriminatebetween these two entities (Sasaki et al., 1983; Cuneoet al., 1996; Soupiret al., 2007). First,in contrastto CML,karyotypicnomalization occurs duringremissionof AML. However,with the adventof imatiniband related drugs for the treatmentof CML, this is now a less pertinentargument.Second, patients with t(9;22)-positiveAML often have a mixtureof cytogenetically abnormalandnormal cells at diagnosis; this is rare in CML. Third, although some secondary changes are

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similar, as noted above, they are less uniform in distributionin AML than they are in CML. Fourth,AML with t(9;22) may express the P190 BCWABLl transcript,whereas CML cases practicallyalways express the P210 transcript(Chapter7). Finally,patients with t(9;22)-positive AML are less likely to have splenomegaly and peripheral basophilia. The BCR breakpointsin t(9;22)-positiveAML have, as in ALL (Chapter9), been shown to map either to the major breakpointcluster region, leading to the P210 BCWABLI transcript,or,less frequently,upstreamof this region,resultingin P190 BCWABLI (Erikson et al., 1986;Chenet al., 1988).Theclinicalimplicationsof thesetwo transcriptsdo notseem to differsignificantly(Kantarjianet al., 1991;Tien et al., 1992). Forfurtherinformationon the pathogeneticimpact of BCWABLI, see Chapter7. Sasakiet al. (1975) werethe firstto detectthet(9;22)in AML.Additionalt(9;22)-positive AML were subsequently published during the late 1970s clearly showing that this translocationwas not restrictedto CML or ALL. To date, close to 200 AML cases with t(9;22) have been reported.Among these, the t(9;22) is morecommon in males, with a sex ratioof 1.5. It occursin all age groupsbut is particularlyfrequentin youngerand middleaged adults;the median age is roughly45 years. Most t(9;22)-positiveAML are morphologicallyclassifiedas MI or M2; however,it is relativelycommonalso in otherFAB types, mainlyMO, M4,orM7. Theblastsoftendisplay both myeloid and lymphoid features,including rearrangementsof the immunoglobulin heavy-chainand the T-cell receptorbeta genes and expressionof severallineage antigens, such as the stem cell antigenCD34, the myeloid markersCD 13 and CD33, and the B-cell markersCDl 0 andCD19;thispresumablyreflectsthe immaturenatureof the hematopoietic cell in whichthetranslocationarises(Chenet al., 1988;Tien et al., 1995;Cuneoet al., 1996; Casasnovaset al., 1998; Soupiret al., 2007). Less than 5% of patients with t(9;22)-positive AML have a previous history of chemotherapy,and t-AML with this translocationare not specifically associatedwith any particulartreatmentmodality.They may occur after radiotherapyalone or after chemotherapywith alkylatingagents or DNA topoisomeraseI1 inhibitors(Block et al., 2002; Mauritzsonet al., 2002). That t(9;22)-positiveAML respondspoorly to chemotherapy, conferringa dismal survival,was shown in the 1970s by Bloomfieldet al. (1977) and Abe and Sandberg(1979). Subsequentstudieson the prognosticimpactof t(9;22) in AML have confirmedthat complete remission is rarely achieved with conventional chemotherapy (Cuneoet al., 1996; Soupiret al., 2007) and that responseto imatinibis usually of short duration.Thus, the t(9;22) should definitelybe included in the groupof poor cytogenetic risk factors in AML. It is questionablewhether SCT improves the outcome (Armand et al., 2007).

t(l0;ll)(pl2;ql4) Approximately 30 AML cases with t(I0;1 I)(p12;q14) involving the PICALM and MLLTIO genes have been reported.Also a few ALL cases with this chimerahave been published (Chapter9). It is importantto stress the presence of the PICALM/MLLTlO fusion, because the t(10;1 1 ) may at the cytogenetic level easily be misinterpretedas a variantof the morecommonrearrangement between 1Op12 and 1 1q23, which resultsin the MLUMLLlO fusion [see 10p12/1lq23 Rearrangementssection below). The t( 1O;ll) has been the sole change in more than half of the cases. No specifically associatedsecondary changes are seen.

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Dreyling et al. ( 1996) showed thatthe t( 10;I 1) in the U937 cell line, widely used as an in vitro model for monocytedifferentiation,fuses PICALM (phosphatidylinositolbinding clathrinassembly protein,previously CALM) at 1 lq14 with MLLTlO (initiallyAFIO) at 1 Op 12. Both PlCALM/MLLTIO andMLLTlO/PlCALM transcriptswereexpressed.Because the lattercoded for a small MLLTlOprotein, truncatedbecause of a stop codon from PlCALM, they concluded that the formerchimera,transcribedfrom the der(lo), was the leukemogenicone. Subsequentstudies (Kobayashiet al., 1997b; Dreyling et al., 1998; Carlsonet al., 2000) confirmedthis fusion in severalt( lO;ll)-positiveA M L andalso in Band T-lineageALL. Because of the variablemorphologicand immunologicphenotypes,it was suggested that the t( 1 0 1 1) arises in a multipotentor very early precursorcell. The pathogeneticconsequencesof PICALM/MLLTIO remainto be elucidated,althoughit has been shownto induceacuteleukemiain mice andto impairdifferentiationof hematopoietic cells, partlythroughan upregulationof HOXA genes (Caudelland Aplan, 2008). The t( 10;1 1 ) is equally common in males and females. It mainly occurs in children, adolescents,and young adults, with a median age of 20 years. Although the PICALM/ MLLTZO fusion has been reportedin most Ah4L subtypes,severalgroupshaveemphasized thatmany of the cases show a ratherimmaturemorphology(MOor M I ). They oftendisplay an immunophenotypeof mixed lineage, with frequentcoexpressionof myeloid and T-cell antigens.In addition,rearrangementsof the immunoglobulinheavy-chainand the T-cell receptorgenes are common (Dreyling et al., 1998; La Starzaet al., 2006; Caudell and Aplan, 2008). PICALM/MLLTI O-positivecases respondpoorly to chemotherapyand are hence associatedwith a dismal outcome.

10~12111 q23 Rearrangements Complexrearrangements involving I Opl 1- 1 3 ( 1Op 12 is used as it indicatesthe locationof the MLLTlO gene) and 1 lq23 have been reported in roughly 100 AML cases. The abnormalitieshave been variably described as, for example, derivativechromosomes includingt( 10;1 I)(p12;q23),inv( 1 l)(q13q23), and insertionsof lop into 1 lq or vice versa. Such changesoccur in 0.5%of all cytogeneticallyabnormalAML, makingthem the third most frequentI lq23 aberrationsin this disease, aftert(9;l l)(p21;q23) and t( 1 1;19)(q23; pl3). Additionalabnormalitiesare found in 50%of the cases, with +8, 19, and +21 as the most frequent. Chaplinet al. (1995) showed that 1Op12/1lq23 rearrangements fuse MLL to MLLTIO. Even thoughsome of the abnormalitieshad quitedifferentlop breakpoints,as ascertained by chromosomebanding,they resultedin an MLUMLLTIO chimera.Only this transcript, not the reciprocalone, was expressed.The complexityof the various 1Op/l lq rearrangements,includingmoreproximal1 I q breakpoints,was investigatedby Beverlooet al. ( 1995). They performeda detailed characterizationof these changes and showed an opposite orientationof the two genes. Thus,two breaksas seen in a simple reciprocaltranslocation arenot sufficientto createan in-framefusion;at least threebreaksareneeded.Considering the cytogeneticheterogeneityof the various aberrationsleadingto MLUMLLTIO, an AML M5 with abnormalitiesof 1Op and 1 1 q, almost irrespectiveof the bandsinvolved, shouldbe suspectedto harborthis fusion. Hence, FISH or RT-PCRanalysesshouldbe consideredin suchcases. A summaryof the pathogeneticimpactof variousMLL fusionsin AML is given in 1lq23 Rearrangementssection. AML with 1Op12/1lq23 rearrangementsare more common in males than in females, with an SR of 1.4, and are mainly found in infantsand children(the median age is only

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ACUTE MYELOID LEUKEMIA

2 years). In agreement with this, molecular analyses of pediatric AML with M U rearrangementshave identifiedthe M W L L T / O chimerain roughly 15%of such cases: the correspondingfrequencyin adultcases is only 5% (Meyer et al., 2006). was an ins(10;1 I)(pl I ;q23q24)in an infantAML The first 10p12f I lq23 rearrangement M5, describedby Kanekoet al. (1 982). Soon afterwardseveralsimilar,often inverted,11q insertionsinto lop were identifiedin M5 or M4. Aberrationsinvolving the same bandsat 1Op but more proximalones on 1 lq were also reportedin AML M5 (Carteret al., 1991). These changes are now known to representder(10)t(lO;1 l)(p12;q23)inv(1l)(ql3q23), based on the study by Beverloo et al. (1995). In the large series of IOp12/1lq23-positive AMLreportedby Lillingtonet al. (1998) andCasillaset al. (2003), a close associationwith M5 morphology(most often M5a) was confirmed,with the blastsoften expressingCD13, have been CDl I CD14, CD33, and CD34. Only a handfult-AML with this rearrangement reportedhence, most cases are de novo leukemias.Lillingtonet al. (1998) reportedthat childrenaged 1-14 years often achieved remission.whereas infantsand elderly patients faredpoorly.A dismaloutcomein the latterage groupshas subsequentlybeen emphasized in several studies (Dreylinget al., 1998; Casillas et al., 2003).

Trisomy 11 Trisomy 11 occurs in 2-3% of cytogeneticallyabnormalAML, makingit one of the most commonchromosomegains in this disease. Only +8, +21, and 19 are moreprevalent, whereas + 13and +22 are seen at similarfrequencies.Morethan400 AMLcases with 11 have been published,with the trisomybeing the sole changein roughly40%.In contrastto severalothernumericalchanges,suchas -7 and 8, trisomy1 1 is nota commonsecondary aberrationto any AML-associatedtranslocationsor inversions.Instead, 1 1 often occurs togetherwith other numericalanomaliesin AML. The pathogeneticallyimportantmoleculargeneticconsequencesof 1 1 areunknown. However,ITD of the MLL gene has been reportedin a substantialproportion(2540%)of AML with trisomy 1 1 as the sole anomaly,with the MLL ITD being restrictedto one of the three chromosomes 11 and relatively often associated with concomitant FLT3 ITD (Caligiuriet al., 1994, 1997;Slovaketal., 1995;Schnittgeret al., 2000; Steudelet al., 2003; Rege-Cambrinet al., 2005). Although the MLL ITD is most likely of pathogenetic importance,it may perhapsbe too simplistic to ascribe the functionallyessential consequence of + 1 1 to the rearrangementof a single gene on that chromosome. Trisomy I 1 as the sole anomalyis more commonin men thanin woman (SR 1.4). The changemainlyoccurs in middle-agedand elderlypatients,with a medianage of 60 years. Although trisomy 11 as the sole change in AML was first reported in the early 1980s (Hagemeijeret al., 1981; Yunis et al., 1981>,it was not recognizedas a nonrandom AML-associatedaberrationuntilDanget al. ( 1985)revieweda handfulof suchcases. Larger series have since been published,identifyingseveralclinical characteristicsof AML with 1 1 (UKCCG, 1992a;Bilhou-Naberaet al., 1994; Slovak et al., 1995; Faraget al., 2002; Rege-Cambrinet al., 2005). It has, for example,been shownthatmost AML with 1 I are de n o w ,at leastin the sensethatthey arenot associatedwith priorchemotherapy.However, many ariseaftera priorMDS phaseand display trilineagedysplasia.Thereis a preponderance of MI, M2, or M4, often with Auer rods, and the blasts usually express HLA-DR, CDl3, CD15, CD33, andCD34. Most studieshave reporteda poorresponseto chemotherapy and an unfavorableprognosis,with the outcome being particularlydismal for cases with ITD of MLL andforFLT3.

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CHARACTERISTICCHROMOSOMEABNORMALITIESIN AML

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inv(1l)(pl5q22) This inversion has been described in almost 25 AML cases, making it the second most common11p 1 YNUP98 rearrangement; only t(7;1 1 )(p I5;p15) is morefrequent.It is the sole anomalyin roughly60%of the cases; the only recurrentsecondarychanges to date have been +8and +21. The inv(1 1) was shownby Araiet al. (1 997) to resultin a fusionbetweenNUP98 at I 1 p I5 andDDXlO (DEAD (Asp-Glu-Ala-Asp) box polypeptide)at 1 lq22. They suggestedthat the NUP98/DDXlO transcriptwas the Leukemogenicone because the reciprocalchimera was not expressedin one of the analyzedcases. Several studieshave since confirmedthe presenceof NUP9WDDXIO in inv( I 1)-positiveAML and have shownthatthis fusion also may arisethroughother 1 Ip15/11q22 rearrangements, such as translocationsandinsertions (Nebral et al., 2005; Romanaet al., 2006). The pathogeneticimpact of various NUP98 chimerasis briefly summarizedin section "I I p15 Rearrangements". Theinv(I 1) is slightlymorecommonin malesthanin females,with an SR of I .2. It hasbeen foundin childhoodas well as adultAML;themedianage is 45 years.ThefirstAMLcaseswith inv( I l ) - o n e de n o w andone treatment-related-were reportedby Gibbonset al. (1987) and h i et al.( 1989).Infact,subsequentstudieshave shownthathalfof allNUP98/DDXIO-posi tive cases are t-AML, occurringafterpreviouschemotherapyincludingDNA topoisomeraseI1 inhibitors,with the prevalenceof inv(1 1) beingclearlyhigherin t-AML thanin de novo AML (Kobayashiet al., 1997a;Nebralet al., 2005; Romanaet al., 2006). No specificmorphologic subgrouphas been associated with inv(1 I). The prognosticimplicationof the inversionis unclear,but survivalhas been reportedto be poor in some of the studiesreferredto above.

Approximately15 AML cases with t( 1 I ;20) have been published,makingit the thirdmost common 1 lp15 rearrangement aftert(7;1 l)(p15;p15)and inv( 1 l)(p15q22).The t( 1 1;20)is the sole change in 80%of the cases; no recurrentsecondarychanges have been reported. Ahujaet al. ( I 999) reportedthatthe t( 1 1;20) resultsin a fusionbetweenNUP98 at 1 1p15 and the DNA topoisomeraseI (TOPI) gene at 20q12. Only the NUP98/TOPI transcript, coded for by the der(1 I)t(1 1 ;20), was expressed, strongly suggesting that this was the leukemogenicone. Furthersupportforthis conclusioncamefroman analysisof a three-way translocationthatyielded a der(1 l)t( 1 I ;20) and NUP98/TOPZ butnot a der(20)t(11;20) or TOPINUP98 (Panagopouloset al., 2002). Furtherinformationon the leukemogenicroleof NUP98 rearrangementsis given in section "1 Ip15 Rearrangements" below. The t( 1 1 ;20) is muchmorecommonin women thanin men,with a sex ratioof 3.6, andhas been reportedin childrenas well as adults;the medianage is 25 years. Althoughthe first reportedt( 1 1;20)-positivemyeloid malignancywas a polycythemiaVera (Berger, 1975), subsequentcases havebeen eitherde now AML or t-AML.Approximately50%of the cases have occurredafter multiagentchemotherapyincluding alkylatorsas well as DNA topoisomeraseI1 poisons (Nebralet al., 2005; Romanaet al., 2006). These studieshave also shown thatt( I 1 ;20)-positiveAMLare of variablemorphology,althoughmostfrequentlyM2 or M5, and thatthis aberrationis associatedwith hyperleukocytosisand a poor prognosis.

11pl5 Rearrangements Approximately200 AML cases with balancedrearrangements, mainly translocationsbut also a few inversionsand insertions,involving I lp15 have been published,comprisingI %

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of all karyotypicallyabnormalcases. The various 1 lp15 abnormalitiesareoften (60%)the sole anomaly,with the most common secondarychanges being, in decreasingfrequency order, $8, -18, -7, -5, and -17. Althoughmorethan50 differentbalancedabnormalitieswith breakpointsin 11 p 15 have been reported,most have been describedin single cases only. Thosereportedin 10or more patientsare t(5;l l)(q35;p15), t(7;l l)(p15;p15), inv(1 l)(p15q22), and t(l1;2O)(p15;q12) (see separatesectionsabove).Thus,the clinical ramificationsof most 1 1 p15 translocations are unknowndue to their rarity. it would be Consideringthe frequentinvolvementof NUP98 in 1lp15 rearrangements expectedthatthis is the targelof all abnormalitiesinvolving 11p 15. However,this is not so; NUP98 has been shown to be affectedin only 10-35% of 1l p I5 aberrationsin hematologic malignancies(Kobzev et al., 2004; Nebralet al., 2005; Romanaet al., 2006; van Zutven et al., 2006). Since 1996, when the t(7;1 l)(p15;p15) was shown to rearrangeNUP98, this gene has been revealedto fuse with morethan20 differentgenes in variousmalignancies,mostoften AML but also CML, MDS, and T-cell ALL. In all instances, the S’NUP98B’partner transcriptis expressed, whereas the reciprocaltranscriptmay or may not be expressed. For this reason, the formertranscriptis consideredto be the leukemogenicone. Several reviews of NUP98 abnormalitiesin hematologic malignancieshave been published,for example Lam and Aplan (2001), Nakamura(2005), and Romanaet al. (2006), providing detailedinformationnot only on the normalNUP98 butalso on the variousfusiongenes, as summarizedhere briefly. The nucleoporinN U B8 is an importantcomponentof the nuclearpore complex in the nuclearmembrane,mediatingnucleo-cytoplasmich-ansportof proteinand RNA. NUP98 residesasymmetricallyat the nucleoplasmicside of the NPC, shuttlesbetweenthe nucleus and the cytoplasm, and providesdocking sites for a numberof nucleartransportsignal receptorproteins as well as for mRNA. In addition, NUP98 is a strong transcriptional transactivator throughinteractionwith, for example,CREBBP.Thus,disruptionof NUP98 may affect both the functionof NPC and transcription,with the partnergenes also being criticalfor leukemogenesis. The 20 different genes fused to NUP98 in AML are quite variable, although some recurrentthemesareapparent.A firstdichotomycan be madebetweenhomeoboxgenes and non-homeoboxgenes.The formergroup,whichis thelargestone, includesmostmembersof the HOXfamily;in fact, theHOXA, HOXC,andHOXDclustershaveall been shownto fuse toNUP98asa resultof t(7;l I)(pl5;p15),t( 1 1 ;I 2)(p15;q13),andt(2;I l)(q31 ;p15),respectively. Althoughno involvementof HOXBgenes at 17q21has beenproven,it is noteworthythat several AML with t(l1;17)(p15;q21) have been published;it would be very surprising indeedif it wereto be shownthatthistranslocationdoes not resultin a NUP98/HOXBfusion. A few otherhomeobox genes have also been reportedto recombinewith NUP98, namely, the pairedrelatedhomeobox 1 (PRRXI; initiallyPMXI) and 2 genes (PRRX2),involved in t( 1;1 l)(q24;p15) and t(9;l l)(q34;p15), respectively.Most of the NUP98homebox fusions have been associated with de now myeloid malignancies.As regardstheir pathogenetic consequences, it has been shown that these chimeras, as expected considering the involvementof homeobox genes, are transcriptionfactors and that some of them induce transformation of NIH 3T3 cells in vitro andorare leukemogenicin variousmouse models. The non-homeoboxpartnersin AML can be furthersubgroupedinto cytoplasmicand nucleargenes. However, the former,which compriseADD3 and RAPI GDSl, have only been implicatedin single AML cases; they are more often involved in T-cell ALL. The

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

81

nucleargenes arequiteheterogeneous,butsome functionalsubgroupscan be identified,for example genes coding for DNA topoisomerases,that is, TOP1 and TOP2B, and genes encoding nuclear receptorbinding SET domain proteins (NSDI and WHSCILI). The formerareoftenassociatedwith t-AML,whereasthe lattertypicallyareinvolvedin de novo AML. The other nuclear genes comprise CCDC28A (formerly C60rf8O), DDXlO, FNI, JARIDIA, PHF23, and PSIPl (previouslyLEDGF);of these, only DDXlO is strongly associated with t-AML. The leukemogenic impact of the various NUP98hon-HOX chimerasis less well investigatedthanthatof the ones involvinghomeoboxgenes, although functionaldisruptionof the NPC probablyplays a vital role.

t(ll;17)(q23;q12) [MLLRearrangement] Almost50 AML cases withatranslocationbetweenI 1 q23 and 17q12-2 1 havebeen reported. Althoughsimilarat the cytogeneticlevel, the cases with t(11; 17)havebeen shownto differ molecularlyas well as clinically.One groupis characterizedby variousMLL fusions, all of them withgenes mappingto 17q 12(Fig. 5.1 1 ), whereastheothergrouprearrangestheRARA gene at 17q2 I. Forthis reason,the 17q12breakpointis used above to indicatethe t( 1 1 ;17) andthe 17q21 breakpoint(see t( 1 1; 17)(q23;q2I ) RARA associatedwith MLL rearrangement Rearrangementsection)to indicatethe t( I 1; 17) associatedwith APL. Of the approximately 35 non-APLcases reportedwith t( I 1 ;17), the translocationwas the sole changein 80%;the only recurrentsecondarychangeshave been trisomyfor chromosomes5,8, and 19. Threedifferentgenes on 17q12 have been shown to fuse to MLL as a consequenceof t( I 1; 17). namely MLLT6 (previouslyAFI 7), U S P I , and ACACA (Prasadet al., 1994a; Strehlet al., 2003; Meyeret al., 2005). Involvementof thetwo lattergenes is very rare;most t( 1 1 ;17) resultin MLUMLLT6 (Meyeret al., 2006; Strehlet al., 2006). A brief summaryof the pathogenetic impact of various MLL. fusions in AML is provided in the llq23 Rearrangementssection. The t( 1 1 ;17) is slightly morecommonin males thanin females,with a sex ratioof 1.3. It almostexclusively occursin infants,children,adolescents,or young adults;the medianage is 15 years. The first t(l1;17)-positive AML published was a monoblastic leukemia (Zaccariaet al., 1982). and subsequentreports have confirmeda strongassociation with M4 and M5 (Harrisonet al., 1998;Strehlet al., 2006). Littleis known aboutthe prognostic impactoft( I 1 ; I 7). but in the seriescompiledby Harrisonet al. (1998), none of the patients were long-term survivors,indicatinga dismal outcome.

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FIGURE 5.11 The t(l1;17)(q23;q12) is associated with AML M4 or M5. Arrows indicate breakpoints.

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t(ll;17)(q23;q21) [RARA Rearrangement] As mentionedabove,the t( 1 I; 17) thatrearrangesRARA is cytogeneticallyindistinguishable from the one involving the MLLgene. Thus, when searchingcytogeneticdatabasesfor the differentt( I 1 ;17) abnormalities,the morphology is important,that is, APL for the one affectingRARA and M4M5 for the MU-positive cases. Among approximately15 APL cases with t( 1 1 ;17) reported,the translocationwas the sole changein two-thirds.The only recurrentadditionalanomalyto date has been loss of the Y chromosome. Chenet al. (1993) showedthatthe RAMgene at I 7q2I was fusedtoZBTB16(zincfinger and BTB domaincontaining16, formerlyP U F ) at I lq23. The ZBTBZ6/RARAchimera,as well as the reciprocalone, has since been identified in severalcases, includinga few with cytogenetically cryptic rearrangements(Guidez et al., 1994; Scott et al., 1994; Licht et al., 1995; Grimwadeet al., 2000). Furtherstudies have revealed a close association between PML, the protein involved in t( 15;17)(q22;q21), and ZBTB16. For example, similarlyto P M L M R A ,the ZBTBI6/RARAfusionproteininhibitsthe wild-typeretinoic acid receptorin the presenceof retinoicacid (RA), and PMLandZBTB16 have been shown to interactwith each other (Chen et al., 1994; Koken et al., 1997). Interestingly,mice transgenicforZBTB16/RARA develop leukemiathatis nonresponsiveto ATRA in contrast to leukemiasin PMURARA mice, which respond to such treatment(He et al., 1998). Thereis a pronouncedmale preponderancein t( 1 1;17)-positiveAPL,with an SR of 10. In fact,we know of no otherabnormalityin AML (exceptloss of theY chromosomein malesand idic(X)(q13) in women)thatdisplayssucha genderbias. As yet, t( 11; 17) has not been seen in pediatricAPL;instead,the patientshave been young adults,middleaged or elderly,with a median age of 55 years. The first case, reportedby Chen et al. (1993), had APL-like promyelocyteswithoutAuer rods, and althoughtreatmentwith ATRA resultedin myeloid maturation,noremissionwasachieved.SubsequentstudieshaveshownthattheZBTBI6RARA accountsforroughly 1%of all APL andthatmost patientspresentwithfeaturesindistinguishpromyelocytesintheBM withcommon ablefromclassicalAPL,includingahighpercentageof clinicalandlaboratorysignsof DIC.Notably,theBM morphologyoft(1 1;17)-positivecasesis not easily classified as M3; instead,most blasts have a regularroundor oval nucleus,more suggestiveofM2,andPelger-likecellsarecommon.Similartot(15;17)-positiveAPL,theblasts expressCDl3 and CD33 and arenegativefor HLA-DR and CD34. In contrastto APL with t( 15;17),aberrantCD56expressionis commonin APLwitht( 1 1 ;17)(Guidezetal., 1994;Scott et al., 1994; Lichtet al., 1995;Kokenet al., 1999 Grimwadeet al., 2000, Saintyet al., 2000). The initialreportsoft( I 1 ;I 7) stressedthe adverseprognosticimpactof this abnormality, with poorresponseto ATRA,arsenictrioxide,andconventionalchemotherapy.However,in the largeseriespublishedby Grimwadeet al. (2000), completeremissionwas achievedin all 10 patientstreatedwith combinationchemotherapy,half of whomalso receivedATRA, with six of the patientsremainingalive at the time of reporting.

Almost 30 AML cases with this translocationhave been published,with the t( 1 I ;17) being the sole change in 60%.The most common secondary aberrationsare monosomy 7 and trisomy for chromosomes6, 8, 19, 20, and 21. Thet( I 1 ;17)was shownto resultin a fusionbetweenMUandSEPT9 (formerlyMSFand AFl7q25) by Osakaet al. (1999) andTakiet al. ( I 999). SEPT9is one of severalmembersof the septinfamily thatplays an importantrole in variouscellularprocesses, such as mitosis and vesicle trafficking(Cerveiraet al., 2006; Strehlet al., 2006). Interestingly,otherfamily

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CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

membersare also known to fuse to M U ,namely SEPl2 in t(2;l l)(q37;q23), SEPTS in t( 1 I ;22)(q23;qI 1 ), SEPT6 in complex rearrangementsinvolving Xq24 and 1 1 q23 in AML, and SEPTII in t(4: 1 l)(q2 I ;q23) in chronicneutrophilicleukemia.This t(4;1 1) is cytogeneticallyindistinguishablefromthe t(4;1 1 )(q21 ;q23)of ALL and AML (Megonigal et al., 1998; Borkhardtet al., 2001; Kojimaet al., 2004; Cerveiraet al., 2006). The t( 1 1 ;17) is equally commonin males and females and has been reportedin all age groups,albeit mainly in youngerpatientsresultingin a medianage of 25 years. Although Yunis ( I 984) was the firstto emphasizethatt( 1 1 ;17) was an AML-associatedabnormality, single cases had already been reported in the late 1970s and early 1980s (Golomb et al., 1978; Mitelmanet al., 1981). The translocationis particularlycommon in M4 and M5, althoughsome cases of M 1 or M2 have been reportedand a few MDS and ALL with t(l1;17) have also been described(Harrisonet al., 1998).Roughlyone-thirdof all cases are t-AML, mainly arisingafterchemotherapyincludingDNA topoisomeraseI1 inhibitors.In the series by Harrisonet al. (1998), all patientsexcept one had succumbedto the disease, stronglyindicatingthat the t( 1 1 :17) confers a poor prognosis.

t(l1;19)(q23;p13) The t( I I ;19) has been reportedin almost 150 AML cases, most often (75%) as the sole chromosomechange.This makesit the second most common 1 lq23 translocationin AML. aftert(9;I l)(p2 I ;q23),occurringin close to 1%ofcytogeneticallyabnormalAML.Trisomy 8 is seen in 15%;no othersecondarychangeis particularlyfrequent.Therearetwo typesof t( 1 1 ;I 9)-positive AML, namely one with t( I I ;19)(q23;p13.1) and one with t(l1;19)(q23; p13.3). The formeris more often the sole aberration,whereasthe latteris associatedwith additionalchanges in roughlyhalf of the cases (Mr6zeket al., 1997; Moormanet al., 1998; Bloomfield et al., 2002). More than 100 ALL cases with t( Il;19)(q23;p13.3) have been published,with the translocationas an isolatedaberrationin 65%and with +X as the most common secondarychange (Chapter9). Thus, the t( 1 1;19) is heterogeneousboth at the cytogeneticandthe moleculargenetic level, involvingdifferentsubbandsof 19p1 3 ( 19p13.1 and 19p13.3) andat leastfourdifferentgenes (seebelow). As a consequence,clinico-genetic associationsare difficult to ascertainand review as many reportshave not distinguished between the various 19p translocations.This is unfortunatebecause the cytogenetid moleculargenetic heterogeneityof the t( I I; 19) has been shown to translateinto clinical differences,at least as regardsage andtype of hematologicmalignancy,as discussedlater. Kamanoet al. ( 1988)and Katzet al. (1 988) werethe firstto describet( 1 1;19)-positiveAML using subbandsof 19p13 to indicatethe breakpoints.Mitaniet al. ( 1989), applyingin situ hybridization,showed thatthe 19p13breakpointswere variable,being moredistal in ALL than in AML. Furtherstudies of largerpatient series have since clearly delineated two differenttranslocations(Huretet al., 1993;Moormanet al., 1998).The t( 1 1 ;19)(q23;pl3.I ), that is, the one with a proximal 19p breakpoint,is identifiedcytogeneticallyas 1 lq and I9p- that are easy to detect by R-bandingbut less obvious by G-banding.In contrast,the t(l1;19)(q23;p13.3) is seen as l l q - and 1 9 p t and is readilydetectedby G-bandingbut not by R-banding.A FISH assay that distinguishesbetween the two translocationswas reportedby Biggerstaff et al. (2006). Thirmanet al. ( 1994) cloned the “eleven-nineteenlysine-rich leukemia” ELL gene (formerlyMEN) in AML with t( 1 1; 19)(q23;p13.I), identifyingan M W E L L fusion, and Shilatifardet al. (1996) subsequentlyshowed that ELL encodes an RNA polymeraseI1 elongationfactor.This, togetherwith the finding thatthe MLLELLchimericproteinwas

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localized in the nucleus, suggested that the functionaloutcome of the fusion is altered transcriptionregulation(Kandaet al., 1997). The ELL gene is a frequentMLL partnerin AML, being involved in 10%of all MLLpositivecases (Meyeret al., 2006). As regardsthe t( 11;19)(q23;~13.3), Tkachuketal. (1992) reportedthatit leadsto a fusionbetweenMLLat 1 lq23 and the MLLTl (previously ENL and LTG19) at 19~13.3.The lattergene shares sequencehomology with the MLLT3gene, rearrangedas a consequenceof the t(9;1l)(p2 1 ; q23) (see separatesection above). The MLUMLLTl fusion has been shown to induce myeloid leukemiain mice, indicatinga directleukemogeniceffect of this chimera(Lavau et al., 1997). Apartfrom ELLand MLLTI,two fusions betweenMLL and othergenes on 19pl3have been reportedin single AML cases, namely SH3GL1(SH3-domainGRBZlike 1,formerlyEEN)[t(l1;19)(q23;~13.3)) andMYOlF(my0sinIF)[t(11;19)(q23;pl3.2)](So et al.. 1997; Taki et al., 2005). The t( I I ;I9)(q23;p13) is equallycommonin males andin femalesandoccursin all age groups,with a medianage of 25 years. However, this age distributiononly appliesif the variable19p13 breakpointsare not takeninto account.Based on the seriesreportedby Hum et al. (1993) andMoormanet al. (1998), it is quiteclearthatthetwo differentt( 1 I ;19)occurin differentage groups.The one with a 19p13.1IELLrearrangement is mainly found in adults, witha medianage of approximately50 years,althoughit hasbeen reportedin a few childhood cases, includinginfant AML. The involvementof 19p13.3/MLLTZis seen in infantsand children,with a medianage of cl year;however, some adultcases have also been reported. The first t(l1;19)-positive AML, one M4 and one M5, were reported by Morse et al. (1979) and Prigoginaet al. (1979). Subsequentstudies not only confirmeda close associationwith these morphologicsubtypesbut also showed thatthe immunophenotypic features were often myeloid as well as lymphoid, with some cases switching lineage between diagnosis and relapse; in fact, the t( 1 I ;I 9) has been reportedto be the most commontranslocationin AML expressinglymphoidmarkers(Hayashiet al., 1985;Hudson et al., 1991;Cuneoet al., 1992). The t(l1;19)(q23;~13.1) has so far only been reportedin AML, mainlyM4 or M5, whereasthe t( I 1 ;19)(q23;p13.3)is mainly foundin ALL andto a lesserextentin AML (M4 or M5) andbiphenotypicleukemia(Huretet al., 1993;Moorman et al., 1998).The blastsin botht( 1 1 ;19)-positiveAML typesaretypicallypositiveforHLADR, CD13, CD14, CD15, CD33, and CD34. Treatment-related AML with t( I 1;19) were firstreportedby DeVoreet al. (1989)andPui et al. (1 989). Severalreportshave since revealeda strongassociationbetweent( 1 1;19) and t-AML arisingafterprevioustreatmentwith topoisomeraseI1 poisons. In fact, 20-30% of t(l1;19)-positive AML are t-AML (Huret et al., 1993; Felix et al., 1995; Moorman et al., 1998; Secker-Walkeret al., 1998; Bloomfield et al., 2002). Blanco el al. (2001) reportedan interestingpatientwith highhyperdiploidALL in whomtheMWMLLTlfusion emerged6 monthsaftertreatmentwith only one dose of daunorubicinand two doses of etoposide;t-AML was first diagnosed after2 years. This led to the conclusionthat cells carryingthe translocationwere able to proliferateduringongoing chemotherapy. As for most 1 1923 translocations,massive leukocytosisis commonin t( 1I;I9)-positive AMLandtheprognosishas beenreportedto be poor(Huretet al., 1993;Mr6zeket al., 1997; Moormanet al., 1998; Byrd et al., 2002). 1lq23 Rearrangements

Several AML-associatedabnormalitiesinvolving I lq23/MLG-t( 1;I L)(q2I ;q23), t(4;1 1) (q21;q23), t(5;l l)(q31;q23), t(6;l l)(q27;q23), t(9;l l)(p21;q23), 1Op12/1lq23 rearrange-

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

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ments, t(l1;17)(q23;q12),t( 11;17)(q23;q25),t(l 1;19)(q23;p13.1),and t( 1 1;19)(q23;p13.3)-are discussed in separatesections above. However, numerousother aberrationsaffecting I lq23 have also been described.Herewe attemptto summarizesome of the generalaspects of such rearrangements. Abnormalitiesof 1 lq23 arefound in 7 4 % of all cytogeneticallyabnormalAML, often (60%)as the sole change. Balanced aberrations-mainly translocationsbut also some insertions and inversions-are most common, comprising 5d%,whereas unbalanced changes, such as deletions and additions, constitute only 1-2%. The most frequent secondaryanomalies to balanced 1 lq23 rearrangementsare trisomiesfor chromosomes 8, 19, 21, and 6 and monosomy 7, with the patternsof additionalabnormalitiesto some extent differingamong the various I 1923 translocations. At the beginningof the 199Os, several groupsidentifiedthe gene rearrangedin 1 lq23 translocations.and the gene/locus was given differentnames by differentinvestigators, namely ALL-I (acute lymphoblastic leukemia) (Cimino et al., 1991), HRX (human trithorax)(Tkachuket al., 1992),HTRXl (humantrithorax-like geneI ) (Djabaliet al., 1992), andMLL (myeloid/lymphoidormixed-lineageleukemia)(Ziemin-vanderPoel et al., 1991 ). The latter is now the official gene designation. Furtherstudies soon revealed that the breakpointsin the MLL gene clusteredwithinan 8.3-kbregion,irrespectiveof typeof 1lq23 translocationor whetherde novo or treatmentrelated.The M U translocationsoften were accompaniedby deletions downstreamof the breakpointcluster,strongly suggestingthat the der(11) was the importantcomponentin leukemogenesis(Corralet al., 1993; Hunger et al., 1993;Thirmanet al., 1993; Felix et al., 1995). To date, 55 differentpartnergenes to M L Lhave been identifiedin varioushematologicmalignancies,mainlyin acute leukemias butalso in someCML,MDS, andlymphomas.In AML alone,45 partnershavebeen cloned, makingMLL the most promiscuousof all neoplasia-associatedgenes involved in fusions. However,despite its promiscuity,M U does have some favoritepartnersin AML, namely, MLLT3, MLLTI, MLLTIO, M U T 4 , andELL. Most otherfusionshaveonly been reportedin a few, or even single, cases (Meyer et al., 2006). Severalreviews on MLL, the molecular mechanismsmediatedby the MLLfusion proteinsin leukemogenesis,andthe pathogenetic impactof thevarious1 lq23 translocationshavebeen publishedduringthelastfew years,for example Ayton and Cleary (2001), Aplan (2006), Felix et al. (2006), and Krivtsov and Armstrong(2007). Some of these aspects are briefly summarizedbelow. The MLL gene, which is homologous to the epigenetic transcriptionalregulator trithorax in Drosophifu mefunoguster, codes for a DNA binding methyltransferase involved in histone methylationand in the regulationof HOX gene expression.It plays a vital role in embryonicdevelopment,also of the hematopoieticsystem. One important function of MLL is to maintainHOX gene expressionduringembryogenesis.To explain the promiscuous nature of MLL. several different mechanismshave been implicated, including recombinationmediated by VDJ, Alu elements, DNA topoisomerase11, and nonhomologousend joining. However, one single mechanismcannot explain all 1 1 q23 rearrangements,nor is one mechanism involved in all cases with the same 1lq23 translocation. As regardsthevariousMLL gene fusions,it has now been firmlyestablishedthattheMLL chimeras,in which the amino-terminusof MLLis fused in-framewith the partnerproteins, act via a dominantgain-of-functionmechanism,with the methyltransferase activitybeing lost in the fusionprotein.Some of the partnerscontributetranscriptional effectorproperties to MLL, and many arenormallywidely expressed,also in hematopoieticcells. In general, the partnergenes encode proteins that may be divided into those involved in signal

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transduction,suchas MLLT4andSEPT6, andthoseinvolvedin transcriptional regulation,for example MLLT3and ELL. These are often referredto as cytoplasmicand nuclearfusion partners,respectively. A third and as yet smaller group consists of various septins, as exemplified by the t( I 1;17)(q23;q25)discussed above. A fourth group of histone acetyltransferases(encodedby CREBBP andEP300) hasalsobeen delineated.Althoughtheroleof the variouspartnersis debated,it has been clearlydemonstratedthatthey arenecessaryfor leukemogenesis,and thattruncationof MLLis not suficient. Althoughmuchremainsto be elucidatedconcerningthe mechanismsunderlyingMLL-driventumorigenesis,it seems that they areheterogeneousandincludetranscriptional activationfornuclearfusions,dimerization or oligomerizationfor cytoplasmicfusions, as well as structuralchangesof the chromatin. Apartfrombeing involved in variousI lq23 translocations,the MLL gene has also been shownto harborITD (Caligiuriet al., 1994; Baseckeet al., 2006). These self-fusionsarethe most common MLL rearrangementsin adult AML, occurringin roughly 5% and being particularlycommon (25-90%) in trisomy ll-positive AML and in cases with a normal karyotype(10%).In contrast,the prevalencein childhoodAMLis only 1%.Most,butnotall studies,have reportedthatMLL ITD confer a worse prognosis. Anothertype of MLLabnormalitywas morerecentlydescribedin AML, namelyintra-or extrachromosomalamplificationof the gene that, albeit rarely,may also be rearranged. Althoughit shouldbe emphasizedthatthe ampliconsarenot restrictedto MLL,this gene has been shownto be differentiallyexpressedin AMLwith 1 I q23 amplifications.Mostcasesare cytogeneticallycomplex, often hypodiploid,and they frequentlyshow whole or partial losses of chromosomes5 and7 as well as TP53mutations.The patientsare mainlyelderly, oftenwith a previoushistoryof treatmentwith alkylatingagentsandwith BM dysplasia,and theirprognosishas been reportedto be poor (Cuthbertet al., 2000; Michauxet al., 2000; Streubelet al., 2000; Andersenet al., 2001; Poppe et al., 2004; Zatkovaet al., 2004). The identificationof the MLLgene made it possible to use (cyto)molecularmethodsto Suchanalyseshaveshownthat ascertainits involvementin differentI lq23 rearrangements. most, but definitelynot all, balanced 1 lq23 translocationsaffect the MLL gene, whereas several unbalancedchanges,such as deletionsand unbalancedtranslocations,often do not rearrangethis gene (Kearneyet al., 1992;Kobayashiet al., 1993b;Archimbaudet al., 1998; Harbottet al., 1998;Cox et al., 2004). Hence, I 1q23 abnormalitiesdo not by necessityresult in MLL rearrangements. Prigoginaet al. (1979) and Bergeret al. (1980) were the firstto emphasizethat 1 lq23 rearrangements are associatedwith AML, often with a monoblastic/monocyticmorphology. That 1 lq23/MLL-positiveAML most often are M4 or M5 was quickly confirmedby several groups. Unselected AML cases with 1 lq23 aberrations,balanced as well as unbalanced,are distributedamong the various morphologicsubgroupsas follows: 45% M5, 30% M4, 10% M2, 5% MO, and 5% MI; the remainingfew cases are M6 or M7. Furthermore, abnormalitiesinvolving 1 lq23 arefoundin 35 and 10%of all cytogenetically abnormalM5 andM4, respectively,but in less than 10%of MO, MI, M2, M3, M6, and M7, againemphasizingthe strongassociationwith M5 and,to a lesser extent,M4. The I lq23positiveAMLblastsfrequentlyexpressthe stemcell andmyeloidantigensHLD-DR,CD1I, CD 14, CD15, CD18, CD32, CD33, CD34, CD64, andC D l l 7 as well as lymphoidmarkers, such as TdT,CD4, CD7, CD 19, and CD22, althoughexpressionof the latterhas not been confirmed in all studies (Cuneo et al., 1992; Baer et al., 1998; Casasnovaset al., 1998; Hm%kand Porwit-MacDonald,2002; Munoz et al., 2003). Kanekoet al. ( 1982)reporteda higherincidenceof 1 1q23 abnormalitiesin pediatricthan in adult AML. Subsequentmolecular genetic analyses revealed that the MLL gene is

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

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rearrangedin 5 0 4 0 % of infant acute leukemia, especially in childrenbelow the age of 6 months with M4/M5 (Ciminoet al., 1993; Sorensenet al., 1994; Satakeet al., 1999). Furthermore, aberrationsof I lq23 arealso themost commonchangesin noninfantpediatric AML, occurringin 20-25% of the cases (Raimondiet al., 1999; Forestieret al., 2003) and with the t(9; 1 l)(p21;q23)accountingforhalf of these.In contrast,only I-5% of adultAML (Byrd et al., 2002; Munoz et al., 2003; Schoch et al., 2003; harbor1 lq23 rearrangements Cox et al., 2004; Sandersonet al., 2006). A relationshipbetween priorchemotherapywith epipodophyllotoxinsand doxorubicin and subsequentdevelopmentof 1 lq23-positiveAML, most often M4M5 withouta prior MDS and with a short latency period,was first suggested and then clearly confirmedby several groups in the 1980s (Dewald et al., 1983; Weh et al., 1986; Ratainet al., 1987; Pedersen-Bjergaard et al., 1988; DeVore et al., 1989; Pui et al., 1989). Approximatelyone (Mauritzsonet al., 2002), thirdof all AML with 1lq23 translocationsaretreatment-related with M U rearrangementsrepresenting10% of all t-AML in adults(Schochet al., 2003). However,the prevalenceof t-AMLamongthe various 1 lq23 subgroupsvariesextensively, from almost 100% in cases with t(l1;16)(q23;p13), 30-50% in t(9;Il)- and t(ll;l9)positiveAML, to less than5% of those with t(6;1 1)(q27;q23)(Rowley et al., 1997; SeckerWalker et al., 1998). This is also reflected in the large series of t-AML with I lq23 aberrationsreportedby Bloomfield et al. (2002), in which the most common translocation partnerswere 9~21-22, 19~13.3,and 19~13.1. Clinically,most patientspresentwith an often pronouncedhyperleukocytosis;EML is also relatively common, occurringmainly in the skin, lymph nodes, gingiva, abdomen, orbit, or thorax (Kaneko et al., 1988; Kalwinskyet al., 1990; Archimbaudet al., 1998; Johanssonet al., 2000; Parket al., 2002; Changet al., 2004). It has been repeatedlyreported thatAML-patientswith 1 lq23/MLLabnormalities,exceptt(9;1l)(p21;q23),respondpoorly to treatmentand hence have a dismalprognosis.However,some encouragingresultshave been obtainedby SCT (Kalwinskyet al., 1990; Felix et al., 1995; Mr6zek et al., 1997; Archimbaudet al., 1998;Baeret aI., 1998;Forrestet al., 1998; Munozet al., 2003; Schoch et al., 2003).

12p Rearrangements Rearrangementsof the short arm of chromosome 12, most often resulting in loss of chromosomalmaterial,are seen in 5% of cytogenetically abnormalAML; such changes are also quite common in otherhematologicmalignancies,mainly ALL (10%)and MDS (5%) (Chapters6 and 9). In AML, 12p aberrationsare most frequently(80%) observed in complex karyotypesthat often also harborwhole or partiallosses of chromosomes5 and 7. Although unbalancedchanges are most common, several balanced 12p rearrangements have been identified in AML, such as the t(3;12)(q26;p13), t(4;12)(q12;p13), and t(7;12)(q36;p13) described above. When 12p abnormalitiesare found as sole changes, however, balanced translocationsare common, occurring in almost half of the cases. In the 199Os,FISHstudiesof a wide spectrumof hematologicmalignanciesrevealedthat , the E W 6 gene, the breakpointsin many 12p translocationsclusteredin 1 2 ~ 1 3involving andthatthe I2pdeletionswereinterstitialwitha minimaldeletedregionof 1-2 Mbbetween ETV6andthe cyclin-dependentkinaseinhibitor1B (CDKNIB,formerlyKIP1 or P27KIPI) gene (Kobayashiet al., 1994;Satoetal., 1995;Hoglundetal., 1996;Andreassonet al., 1998; Wlodarskaet al., 1998). However,severalstudiesdid not identifyany involvementof ETV6

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in a substantialproportionof cases with balanced 1 2 ~ 1 aberrations 3 (Bergeret al., 1997; 3 Sat0 et al., 1997; Streubelet al., 1998; La Starzaet al., 1999). Thus, 1 2 ~ 1 translocations shouldnot apriori be consideredsynonymouswith ETV6rearrangements, althoughETV6is now known to be fused to more than 25 differentgenes in various neoplasticdisorders, hematologicmalignancies,as well as in some solid tumors.Sixteenof thesehaveso farbeen implicatedin AML. While the pathogeneticallyimportanttargetgene(s) in del(l2p), as for most deletions, has not been identified,much informationhas been gained about ETV6 and its plethora of fusionpartners,asreviewedby Bohlander(2005). As mentionedearlier,ETV6, a member of theets (E-26 transformingspecific)transcriptionfactorfamily,is fusedto a largenumber of differentproteinsin neoplasia,andto bringsome orderinto the spectrumof partnersand their functional outcome, Bohlander (2005) trichotomizedthem into protein tyrasine kinases, transcriptionfactors and others, and “unproductive”fusions. The latterdo not seem to resultin meaningfulfusion proteins.Thepathogeneticallyimportantoutcomeof the chimerasin the first group has been shown to be dimerization,mediatedby ETV6, with subsequentconstitutiveactivationof thekinase,whereasthe fusionsbelongingto the second group most likely result in perturbationof normal gene activation due to aberrant transcription.Finally, the creationof truncatedETV6 would suggest either haploinsufficiency or tumorsuppressorfunction.The latteragreeswell with reportsdescribingdeletions or mutationsof the wild-type E W 6 gene in some instances. Rearrangements of I 2p areslightly morecommonin males than in females(SR 1.3) and occur mainly in adults; the median age is 50 years. Although the first AML cases, one de novo and one treatment-related,with 12p deletions were reportedin the mid-1970s (Yamadaand Furusawa,1976; Weinfeld et al., 1977), it took almost a decade before 12p abnormalities(translocationsas well as deletions)were clearly linkedto AML. They were often t-AML arising after treatmentwith alkylating agents or, less commonly, DNA topoisomeraseI1 inhibitors(Wilmothet al., 1985;Zaccariaet al., 2985; Le Beau et al., 1986; Pedersen-Bjergaard and Philip, 1987; UKCCG, 1992b; Block et al., 2002). In fact, the prevalenceof 12p abnormalitiesis significantly higher in t-AML than in de novo AML (Mauritzsonet al., 2002). Daniel et aI. (1985) reportedan associationbetween I2p aberrationsand AML M2 with basophilia,and such changeswere also relativelycommonin the seriesdescribedby Hoyle et al. (1989b).However,thiscorrelationhasnot been emphasizedin laterreports.Thereis no markedFAB subgrouppreference,but 12pchangeshavebeen suggestedto be morefrequent in MOandM6 (Olopadeet al., 1992;Cuneoet al., 1995;Davey et al., 1995).The prognostic impact of 12p rearrangementsis definitely not favorable (UKCCG, 1992b; Streubel et al., 1998), but it is presently unclear how dismal the outcome is, as AML with del (1 2p) is variably includedin the intermediateor poor prognosisrisk groupsby different investigators(Slovak et al., 2000; Byrd et al., 2002; Haferlachet al., 2004; Tallman et al., 2007).

Trisomy 13

+

Trisomy 13 is seen in 2-3% of karyotypicallyabnormalAML,with 13 being the sole changein approximately25%of thecases. Whenadditionalchangesarepresent,trisomy 13 is generallynot associatedwith any characteristic AML-relatedtranslocationsor inversions; instead, it occurs togetherwith other genomic imbalances,mainly numericalanomalies. However, 13 is fairly common in AML with t(6;9)(p22;q34)or t(8;16)(pll;p13).

+

CHARACTERISTICCHROMOSOME ABNORMALITIESIN AML

89

+

Little is known about the leukemogenicimpactof 13, althougha few recent studies have shed some lighton this issue. SincetheFLT3 gene is locatedin 13q12andMLL ITD,as mentioned previously, are common in cases with +1 1, FLT3 ITD were thoughtto be common in cases with trisomy 13. However, that was clearly not the case (Powell et al., 2005). Instead,increasedFLT3expressionas well as RiJNXl mutationswere shown to be presentin almostall cases, indicatingthatthese two changescooperatein trisomy 13associated leukemogenesis(Dicker et al., 2007; Silva et al., 2007). Hsu et al. ( 1979) first associated 13 with myeloidmalignanciesand,since then,several larger series of trisomy 13-positive AML have been published (Dohner et al., 1990 Pedersen and Jensen, 1991b; Baer and Bloomfield, 1992; Soni et al., 1996; Mehta et al., 1998; Faraget al., 2002). They have delineatedquite characteristicfeaturesof this cytogeneticsubtype.Most patientsareelderlymales (with an SR of 2.5 and medianage of 65 years)withoutany previousgenotoxic treatment,presentingwith markedleukocytosis and thrombocytopenia.AlthoughAML with 13 are morphologicallyheterogeneousand havebeen reportedin most FAB types, a substantialproportionhas been classifiedas MOor M 1 . Transformationof an early hematopoieticcell has been implicatedbased on frequent expressionof myeloid as well as lymphoid antigens.Othertypical BM featuresinclude small blasts with few or no granules,hand-mirrorblasts, lack of Auer rods, and trilineage dysplasia.All studieshave emphasizeda low completeremissionrateand brief remission duration.

+

+

t(15;17)(q22;q21) The t( 15; 17) (Fig. 5. I2), or the PMURARA fusion, may be consideredpathognomonicfor APL. Except for a few other RARA rearrangementsin this disease entity, all APL cases harborPMURARA. Hence,the frequencyof this gene fusion in AML almostequalsthatof APL, roughly5%.The t( 15;17) is the sole changein close to 75%of cases, with $8 as the most common secondarychange (1O-15%). Other additional,less frequent aberrations includedel(7q), del(9q), ider(l7)(q1O)t(15; 17), thatis, an isochromosomeof the derivative chromosome 17, and +2 I. In 1976,Rowley andPotterpublisheda seriesof 50 cytogeneticallyanalyzedAML cases, of which two were APL with a del( 17)(qll q2 1) as the sole anomaly.These two cases were laterpresentedseparatelyby Golombet al. (1976), who specifically associatedthe partial 17qdeletionswith APL.Thesamegroup(Rowleyet al., 1977)subsequentlyreporteda third APL with “del(17q).”In thatcase, however,an abnormal15qwith a breakin 15q22was also observed. Based on this, and by reviewing the two formercases, they concludedthat the karyotypicaberrationin all threeAPL was an insertionof band 17q21 into 15q22.However, Kaneko and Sakurai (1977) and Okada et al. (1977), who had observed the same

15

17

FIGURE 5.12 The t( 15;17)(q22;q21)is pathognomonic for APL. Arrows indicate breakpoints.

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ACUTE MYELOID LEUKEMIA

abnormality,suggestedthat it was a t( 15;17)(q22;q21)ratherthanan insertion.Numerous subsequentstudies soon confirmedtheirinterpretationand firmlyestablishedt(15;17) as a remarkablyspecificAPL-associatedcytogeneticabnormality,occurringin close to 100%of pediatricas well as adultAPL, whethertypical(M3) or atypical(M3v). Lowerfrequencies can generally be attributedto technical reasons such as poor chromosomemorphology (Van Den Bergheet al., 1979; Bergeret al., 1981; Hurdet a]., 1982; Alimenaet al., 1984; Larson et al., 1984; Swansburyet al., 1985). The remarkablespecificity of this clinicocytogeneticassociationis furtherunderscoredby the fact thatwhen, albeitrarely,t( 15;17) develops as a secondarychange during CML BC, the ensuing AML exhibits disease characteristicsindistinguishablefromAPL. TheseincludeDIC as well as responseto ATRA (Castaigneet al., 1984; Hogge et al., 1984b; Rosenthalet al., 1995; Scolnik et al., 1998; Wierniket al., 1991). In 1990, differentgroups reportedthat the t( 15;17) resulted in rearrangementof the RARA gene thatcodes for a memberof the steroidhhyroidhormonereceptorsuperfamily (Borrowet al., 1990; Longo et al., 1990), and that the translocationfused RAM to PML (promyelocyticleukemia,formerlymyl) at I5q22 (de The et al., 1990) giving rise to the PMLfRARAtranscript.Thistranscriptis codedforby the der(15)t(15;17) andis expressedin all cases, indicatingits role in mediatingthe leukemogenicprocess (Goddardet al., 1991; Kakizukaet al., 1991;Borrowet al., 1992).Subsequentstudies,as reviewedby, forexample, Lo COCO et al. (1999), Reiter et al. (2004), Scaglioni and Pandolfi (2007), and Vitoux et al. (2007), revealedPMZfRARA fusionsalso in APL with seemingly normalkaryotypes and in APL with atypicalmorphology,indicatingthatthis chimerawas an excellentgenetic markerfor accuratediagnosisas well as for treatmentmonitoring.These reviews provide excellent summariesof the moleculargenetics as well as the pathogenesisof APL. Briefly, transgenicmice expressingPMURARA develop APL, PMLIRARAis a potentrepressorof retinoicacid signaling, and as the chimeric protein also affects the expressionof genes otherwisenot regulatedby RAM,this also suggests a gain of function. Althoughthe PMZfRARAfusion is by far the most common RAM rearrangementin APL, found in > 98%of cases, a few othergenes have also been shownto fuse to RARA in APL, namely NPMl [t(5;17)(q35;q21)],NUMAf [t(11;17)(q13;q21)],zBTB16 [t(l1;17) (q23;q21)], and STATSB (rearrangementwithin 17q21) (Chen et al., 1993; Redner et al., 1996; Wells et al., 1997; Arnouldet al., 1999). In addition,a FIPILURARA fusion generatedthrougha t(4;17)(q12;q21) was recently reportedin juvenile myelomonocytic leukemia(Buijs and Bruin,2007). Thus, the RARA gene is somewhatpromiscuous,albeit mainly rearrangedwith partnerswithin the APL group. After the identificationof PMZfRARA,it was reportedthat this chimeraoccasionally occurredin APL withoutthe typical t( 15;17). as a consequenceof varianttranslocationsor cytogeneticallycryptic insertions(Barangeret al., 1993; Hiorns et al., 1994; Grimwade et al., 1997). This has highlightedthe importanceof combiningcytogeneticand molecular genetic analysesin the properdiagnosisof APL (Grimwadeet al., 2000). Thus, if APL is suspectedbutthe t( 15;17) is not seen cytogenetically,FUH or RT-PCRanalysesshouldbe considered mandatory,not least considering the importance of this abnormalityfor treatmentdecisions. 1t would seem reasonable to believe that the idea to treat APL patients with the differentiatingagent ATRA came from the discovery that RARA was rearrangedin such cases. However,thatwas not so. Alreadyin the early 1980s, Breitmanet al. (1981) showed that RA resulted in terminal differentiationof promyelocytic leukemic cells in v i m , whereascells fromothertypes of AML were nonresponsive.Based on these findings,they

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suggestedthat RA might have therapeuticutility in the treatmentof patientswith APL. A few yearslater,Flynnet al. ( 1 983) used RA to treata patientwith APL that wasrefractoryto chemotherapy.Althoughthe patientsubsequentlysuccumbedto the disease, the treatment led to maturingmyeloid cells in v i v a Soon afterward,additionalpatientswith APL treated with RA were reported with encouragingresults (Nilsson, 1984; Daenen et al., 1986; Fontanaet al., 1986). Largerseriesof APL patientswho respondedvery well to the all-trans form of RA (ATRA) were subsequentlyreportedfrom China(Huanget al., 1988), France (Castaigneet al., 1990), and the United States(Warre11et al., 1991). When combinedwith conventional chemotherapy,hematologic as well as molecular genetic remissions were achieved in 90% of the patients(Fenauxet al., 1993; Mandelliet al., 1997), and ATRA is now incorporatedin the frontlinetherapyof newly diagnosed APL. As noted by Warrell et al. (1991), it is a paradoxthat a genetic abnormality,that is, PMURARA,resultsin the expressionof an alteredreceptorthatconferstherapeuticsensitivityon one of its ligands, causingdifferentiationand subsequentclinical remission.The treatmentof APL is full of surprises;subsequentstudiesshowed clinical efficacy of arsenictrioxide,a drugotherwise generallyconsideredto be a classic poison. Variousarseniccompoundshad,fora long time, been used in traditionalChinese medicine to treat various diseases. During the 197Os, arsenictrioxidewas used to treatAPL in the northeasternregionof Chinawithgreatsuccess. Detailed biological and clinical studiesof this treatmentappearedin the late 1990s (Shen et al., 1997; Soignet et al., 1998), revealing that arsenic trioxide was an effective and relatively safe drug in the treatmentof APL refractoryto ATRA and conventional chemotherapy.The mechanismsbehind the action of ATRA and arsenic trioxide were recently reviewed by Altucci et al. (2007). The t( 15;17)is equallycommonin men and women. It occursin all age groups,although more frequentlyin younger individuals;the median age is roughly 40 years. APL with t( 15;17) is usually characterizedby a predominanceof abnormalpromyelocytes with conspicuousgranulesand bundles of Auer rods, so called “faggot cells” (M3). In some instances,the cells aremicrogranular with an apparentpaucityor absenceof granules;these cells often have a bilobed nuclearshape(M3v). Very rarely,a hyperbasophilicform is seen, with the leukemiccells typicallyhavinga stronglybasophiliccytoplasmwith no or only a few granules (Liso and Bennett, 2003). The blasts typically express CD13, CD33, and CDw65 but are most often negativefor HLA-DR,CD4, CD7, CDLO,CDI I, CD14, CD34, andCD36; aberrantexpressionof CD2 is noteworthy(Ball et al., 1991;Marosiet al., 1992; Casasnovaset al., 1998; Guglielmi et al., 1998; Khalidiet a]., 1998; Hruiikand PorwitMacDonald,2002). MostAPLarede nowcases, butapproximately5%occurafterprevious chemotherapy,mainly with drugstargetingtopoisomerase11, or radiotherapy(Detourmignies et al., 1992; Andersenet al., 2002). Althoughthe outcomeof APL is nowadaysquitefavorable,albeitwith the high tendency for DIC posing a seriousthreat,a proportionof the patientssuccumbto the disease.Several studieshave tried to identify genetic featuresthat may explain the poor survivalin these cases, for example secondary chromosome changes and FLT3 mutations. With a few exceptions,analyses of the clinical impactof additionalabnormalitieshave not identified any influenceon, for example, age, gender,white blood cell count,morphologicsubtype, and prognosis(Slacket al., 1997;Grimwadeet al., 1998;De Bottonet al., 2000; Hernandez et al., 2001). As regardsFLT3, mutationsin this gene aregenerallyrarein conjunctionwith AML-associatedtranslocations,but with two notableexceptions,namely t(6;9)(p22;q34) (see above) and t(l5;17)(q22;q21). In fact, FLT3 ITD or activatingpoint mutationsin APL have been shown to be present in 2 0 4 0 % and 10-20% of cases, respectively

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(Kiyoiet al., 1997;Nogueraetal., 2002; Callenset al., 2005; Galeet al., 2005). Thepresence of such mutationshas been correlatedwith high peripheralblood cell counts and the M3 hypogranularvariantbut has generally not been associated with a significantlyadverse impact on the outcome.

inv(l6)(pl3422)/t(16;16)(pl3;q22) The inv(16) (Fig. 5.13) ort( 16;16) is seen in 4%of cytogeneticallyabnormalAML,with the inversionbeing much more common (95%) than the translocation(5%). The inv(16)/t (1 6;16) is the sole anomalyin 70%;the most frequentsecondarychangesare +22 (15%), +8 (lo%),del(7q) (6%), and +21 (4%). Liu et al. (1993) reportedthatinv(16) resultsin a fusion between CBFB (core binding factorbeta subunit,formerly PEBP2B) at I6q22 and MYHII (myosin heavy chain 1 1, smooth muscle, previously SMMHC/SMHO at 16p13, leading to a chimeric CBFB/ MYHl I protein. Additional studies soon confirmedthe expression of CBFB/MYHll transcriptsin inv( 16)- and in t( 16;16)-positiveM4Eo, as well as in M4 withouteosinophilia, and also detected that the abnormaleosinophils were part of the leukemic cell population.The reciprocaltranscriptwas not producedin some cases due to submicroscopic deletions involving the 5’ part of the MYHII gene, strongly indicatingthat the CBFB/MYHII chimera was the leukemogenic one (Claxton et al., 1994; Marlton et al., 1995a; van der Reijden et al., 1995; Haferlachet al., 1996b). The leukemogenic impactof CBFB/MYHII has since been extensively investigated(Shigesadaet al., 2004; Reilly, 2005). Forexample, it has been shown thatCBFBNYH1 I dominantlyinhibitsthe functionof RUNX 1, leading to gene expression changes and a block in differentiation, while other genetic changes are necessary for overt leukemia, such as KIT and RAS mutations. Since the core binding factor(CBP) transcriptioncomplex consists of the interacting proteinsRUNX 1, involved in t(8;21)(q22;q22),andCBFB, rearrangedin inv(16)/t(16;I6), cases with these changes are often referredto as CBF AML. However, these two AML types should be seen as separate clinical entities with differentprognostic implications and shouldnot be groupedtogetherin clinical trials,as recentlyemphasizedby Marcucci et al. (2005). Yunis et al. (1 98 1) first describedthe inv(16)(pI3q22) in a case of AML. A few years later, a strong association between this inversion and AML with disruption in the eosinophiliclineage was reportedby Le Beau et al. (1983). They emphasizeda favorable prognosisfor patientswith inv(16)-positiveAML. The variantt( 16;16) was then identified

16

FIGURE 5.13 The inv( 16)(p I3q22) is characteristicfor AML M4Eo. Arrowsindicatebreakpoints.

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

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by Hogge et al. ( 1984a)in a seriesof chromosome16 abnormalitiesassociatedwith M4 and dysplastic BM eosinophils. Based on these early studies as well as on numerouslater investigations,inv(I6)/t( 16;16)-positiveAML was recognizedas a specific subgroupwith typical morphologic,immunophenotypic,and clinical features.These characteristicsare also importantwhen performingcytogeneticanalyses,as inv(16) is a subtle anomalythat escapesdetectionin suboptimalchromosomepreparations.Additionalabnormalitiesof the inv(16), often translocations.are not uncommon,and they may mask the presenceof this aberration(de la Chapelleand Lahtinen,1983; Bergeret al., 1995). Hence, if the inv(16) is not found by chromosomebandinganalysis but is clinically suspected,FISH and/or RTPCR should definitelybe used. The inv( 16)/t(16;16)is slightly morecommonin males thanin females(SR 1.3) andhas been reportedin all age groups,includinginfantsas well as octogenarians.Most patients are relativelyyoung; the medianage is roughly35 years. The majorityof AML with inv ( 1 6)/ t( 16;16) are morphologicallyclassifiedas M4 with a variablenumberof eosinophils at all stages of maturation,often with nuclearblebs and Auer rods. This subgroupwas subsequently denoted M4Eo. The close association between these changes and BM eosinophiliais furthersupportedby rareexamplesof inv(16)-positiveCMLBC displaying an M4Eo morphology (Heim et al., 1992; Merzianuet al., 2005; Wu et al., 2006). However,a substantialproportionof cases belong to otherFAB groups,mainly M2. Prior to the WHOclassification,some cases were diagnosedas MDS becausethe percentageof BM blasts was below the cut-off for AML (Campbellet al., 1991;Estey et al., 1992). The blasts typically express HLA-DR, C D l l , CD13, CD14, CD15, CD33, CD34, CD36, CDw65, andCD117, with frequentaberrantexpressionof CD2 (Ball et al., 1991; Marosi et a]., 1992; Adriaansen et al., 1993; Casasnovas et al., 1998; HruEak and PorwitMacDonald,2002). Several studies during the 1980s suggested that AML with inv(16)/t(16;16) had a propensityto relapsewith centralnervoussystem (CNS) involvement,includingleptomeningealdiseaseand intracerebral EML(Holmeset al., 1985a;Glass et al., 1987; Ohyashiki et al., 1988),emphasizingthe need for CNS prophylaxis.The frequencyof CNS leukemia in relapse is nowadays quite low, possibly due to the protective effects of high-dose cytarabinetherapy(Billstromet al., 2002). Most patientspresentwith markedleukocytosis (Grimwadeet al., 1998; Delaunay et al., 2003). The vast majorityof inv(16)/t(16;16)positive AML are de novo. Less than 5% occur afterpreviouschemotherapy(Mauritzson et al., 2002); these t-AML are characterizedby a short latency period, absence of an antecedent MDS phase, and prior exposure to DNA topoisomerase I1 inhibitors or radiotherapy(Quesnel et al., 1993; Andersenet al., 2002). Almost all studies have identified a favorable prognosis for patients with inv(16)/ t( 16;1 6)-positive AML. Some investigatorshave reportedthat these patients have the best outcomeof all cytogeneticAML subgroups,at least in adultsand irrespectiveof the presenceof additionalchromosomechanges.In fact,thepresenceof $22 hasbeen reported to predictan improvedoutcome (Keatinget al., 1987; Fenauxet al., 1989; Kalwinskyet al.. 1990; Dastugueet al., 1995; Marltonet al., 1995b;Grimwadeet al., 1998; Schlenket a]., 2004; Marcucci et al., 2005). Treatmentincluding high-dose cytarabinehas been reportedto be particularlyeffective,akinto the situationin t(8;2l)-positive AML (Ghaddar et al., 1994;Bloomfieldet al., 1998;Appelbaumet al., 2006b). However,somefeatureshave been associated with an inferior outcome, namely advanced age and KIT mutations (Delaunayet al., 2003; Appelbaumet al., 2006b; Paschkaet al., 2006).

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t(16;21)(pll ;q22) Approximately40 AML cases with t( 16;21)have been reported.The translocationwas the sole changein two thirdsof these,withthe most frequentsecondarychangesbeing 4- 10 and 12. In 1994, severalgroupsreportedthatthe t( 16;21) leads to a fusion between FUS (fusion involved in t(12;16) in myxoid liposarcoma;formerly TLS) at 16pll and ERG (v-ets erythroblastosisvirus E26 oncogene homologue) at 21q22 and that the FUPERG, transcribedfromtheder(2l)t(16;2I), andnot the reciprocalone was theleukemogenictranscript (Ichikawaet al., 1994; Panagopouloset al., 1994; Prasadet al., 1994b). Interestingly,the same fusion has been identifiedalso in some Ewing tumors(Shinget al., 2003). FUVERG resultsin perturbation of myeloid differentiation,leadingto accumulationof immaturecells with increased self-renewal. Additional genetic changes are necessary for complete transformationand the chimeratransformshematopoieticcells and fibroblastsin different ways. This is noteworthyconsideringthe presence of the fusion in completely different tumortypes (Warneret al., 2005; Zou et al., 2005). The t( 16;21)is morecommon in males thanin femaleswith an SR of 1.5. It is seen in all age groups,althoughmostoften in olderchildrenandyoungeradults;themedianage is only 25 years.The t( 16;2I ), albeitwith a slightlydifferent16pbreakpoint,was firstdescribedby Mecucciet al. (1985) and,a few yearslater,severaladditionalpatients,all fromJapan,were reported(Minamihisamatsuand Ishihara,1988; Yao et al., 1988). As 25%of all published t( 16;2I )-positiveAML have been fromAsia, this abnormalityseems to displaygeographic frequencyheterogeneity.Initially,the t( 16;21) was thoughtto representa variantof the more common t(8;21)(q22;q22)because of the common 2 1q22 breakpoint,but the molecular genetic consequencesare completely different,as are the clinical implications. Similarto AML with t(8;21), BM eosinophiliais present in almost half of the cases. Otherwisethe morphologyof t( 16;2])-positive AML is quite heterogeneous,with no FAB type preferenceor Auer rods, whereashemophagocytosishas been noted in severalcases (Sadamoriet al., 1990; Kong et al., 1997; Imashuku etal., 2000). The t(l6;21)-positive blastsarepositive for CDl I, CD13, CD18, CD33, and CD34, with frequentexpressionof CD56 andthe interleukin-2receptor01 chain;admittedly,this is basedon examinationof few cases only (Shikamiet al., 1999).Patientsareoften resistantto conventionalchemotherapy, and this abnormalityis therefore strongly associated with a dismal prognosis (Kong et al., 1997).

+

i ( 1 7 M 0) More than I00 AML cases with i( 17)(q10) have been published,with the isochromosome being the sole change in 40%. Common additionalabnormalitiesinclude, in order of decreasingfrequency,+8, -7, -5, 13, I I , 19, and - 12. Thus, i( 17)(q10)is rarelya secondarychangeto characteristicAML-associatedtranslocationsand inversions,butit is a common secondarychange to t(9;22) in CML (Chapter7). It is relativelycommon as an isolatedchangein MDS and MPD, and is occasionallyseen in lymphoiddisorders.In fact, i( 17)(q10)is by farthe most frequentneoplasia-associatedisochromosomeoverall(Mertens et al., 1994). Theessentialmoleculargeneticconsequencesof i( 17)(q10) areunknown.As it resultsin loss of 17p, andthe TP53gene is locatedon thischromosomearm,it hasbeen suggestedthat the functionaloutcomemay be loss of one TP53 allele with an inactivatingmutationof the

+ + +

CHARACTERISTIC CHROMOSOME ABNORMALITIES IN AML

95

otherallele. TP53 mutationshavebeen detectedin a relativelyhigh proportionof AMLwith 17p losses (Lai et al., 1995; Schoch et al., 2005a). However, such mutationshave mainly been identifiedin AML with karyotypesharboring- 17, unbalanced17p translocationsor 17pdeletions, and not in cases with i( 17)(q10)(Schutteet al., 1993;Fioretoset al., 1999). Thus, TP53 does not seem to be the targetof i(l7)(q10). As regardsthe origin of this abnormality,it hasbeen shownto be not a trueisochromosomebuta dicentricchromosome with clusteredbreakpointsin 17pI 1, formedthroughan intrachromosomal recombination event (Fioretoset al., 1999; Barboutiet al., 2004). As a sole change, i( 17)(q10) is clearlymore commonin males thanin females (the sex ratiois 2.3). It occursalmostexclusivelyin elderlypatients,with a medianage of 65 years. The first AML with i( 17)(q10)was reportedby Mitelmanet al. (1973), and by the early 1980s it had been firmly established as an AML-associated aberration(Borgstrom et al., 1982). As a single anomalyi( 17)(q10)has been reportedin all FAB subtypes(except M6). Becheret al. (1990) concludedthatthe presenceof a solitaryi(17)(q10)identifieda distinct subgroupof myelodysplasticand myeloproliferativedisorderscharacterizedby rapidprogressionto AML. Weh et al. (1990) identified severalcharacteristicfeaturesof AML with i( 17)(q10) such as male gender, advancedage, splenomegalyand/or hepatomegaly,prominentbasophiliaandeosinophilia,anddysplasticmegakaryocytes,suggesting an underlyingMDS/MPD.A few CMLcases withcrypticBCWABLI fusionsandi( I7)(q10) as the seemingly sole change have been reported (Mareni et al., 1989; Mohamed et al., 2003). Whereas a substantialproportion of t-AML with monosomy 17, unbalanced 17p translocationsordel(17p)havebeen reported,occurringafterchemotherapywith alkylating agents(Sterkerset al., 1998; Merlatet al., 1999; Mauritzsonet al., 2002), AML with i(17) (q10)is almostalwaysde now, in particularwhen the isochromosomeis the sole change.A poor responseto chemotherapyand short survivalhave been emphasizedin most studies.

del(20q) Deletionsof the long armof chromosome20 arefoundin 1-2% of cytogeneticallyabnormal AML, and in one-third,the del(20q) is the sole anomaly.However,del(20q) is not specific for AML. Such deletions aremorecommonin MPD and MDS, occurringin 15 and 5%of karyotypicallyaberrantcases, respectively(Chapters6 and 8). Abnormalitiesfrequently occurringtogetherwith del(20q) in AML include -5, del(5q), -7, del(7q), $8, -17, and -18. Hence, it is not a common secondary change to AML-associatedtranslocationd inversions. Severallines of evidencestronglyindicatethatdel(20q)is not sufficientforovertleukemia. First, the proportionof mitoses with this abnormality,at least in MDSWD cases, may decrease,occasionallyeven disappear,in subsequentcytogeneticanalyseseven in theabsence of treatment(Aatolaet al., 1992;Matsudaet al., 2000). Second,therearea few examplesof del (20q)-containingBM from patients with undiagnosedMDS being used successfully for transplantation,showing that such cells can home to the BM, proliferate,differentiate,and yield normalperipheralblood values (Redei et al.. 1997; Mielcareket al., 2006). Finally, andmostimportant,del(20q)hasbeen observedin patientswith morphologicallynormalBM and withoutcytopenia(Matsudaet al., 2000; Steensmaet al., 2003). Le Beau et al. (1985) showed that 2% deletions are interstitialand not terminal. Numerouslaterstudieshave attemptedto delineatea minimallycommondeleted segment that might harborthe pathogeneticallyimportanttarget gene(s), for example Roulston

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et al. ( I 993), Bench et al. (2000), and Wanget al. (2000). Recently,aberrantexpressionof theWMBTLgene, locatedat 20q andencodinga memberof the Polycombgroupof proteins thatrepressthe transcriptionof severalloci, hasbeen implicated(Liet al., 2004; MacGrogan et al., 2004). Whetherthis really is “the del(204) gene” is presentlyunknown. Deletionof 2% as an isolatedchangeis morecommonin men thanin women,withan SR of I .7. It occursmainly in adultpatientswith a medianage of 60 years.The del(20q) is not characteristicof any particularFAB subtype.Most cases are de nova AML, with less than 10%being associatedwith previouschemotherapy.The prognosticimpactof del(20q)as a sole changein AML is unclear.It is not a favorableabnormality,as it is in MDS (Chapter6); ratherit has been reportedby differentgroupsto be associatedwith eitheran intermediateor an unfavorableoutcome(CampbellandGarson. 1994; k i t h et al., 1997;Byrdet al., 2002).

Trisomy 21 Trisomy 21 is seen in 5% of karyotypicallyabnormalAML, making it the third most commonnumericalanomaly,after +8 and -7, in thisdisease. It is most often (80%)present togetherwith otheraberrations,mainly othertrisomiesand monosomiessuch as +6, -7, +8, +19, and +22. It is also a relativelycommon secondarychangeto inv(16)/t(16;16). AML with +2 I as a sole change relativelyoften harborsubcloneswith +8. Gain of chromosome21 is common in several hematologicdisorders,being found in 3 4 %of MDS and MPDand in 20%of ALL with abnormalkaryotypes.As a sole anomaly, +2 1 is equallycommon(1%) in AML andALL. Thus,thepresenceof thisabnormalityis of no help in differentiatingbetween these two types of acute leukemia. The pathogeneticallyimportantconsequenceof trisomy 2 1 is unclear.Mutationsin the runtdomainof the R U M 1 gene have been reportedto be relativelycommonin AML with +21. The same mutationis found in two of the threecopies, suggestingduplicationof the mutatedallele. Such mutationsare also common in AML MO irrespectiveof chromosome 21 abnormalities(Preudhommeet al., 2000; Snaddonet al., 2002; Taketaniet al., 2003). As most cases do not harborRUNXI mutations,other mechanismsmust also be involved in trisomy 2 l-associated leukemogenesis. Trisomy2 1 as a sole changein AML is more commonin men thanin women (SR 1.6). It occurs in all age groups,althoughmost often in youngerpatients.The medianage is only 35 years. Gain of chromosome21 is not associatedwith any specific FAB subtypebut has been suggestedto be particularlycommonin MO, M 1, andM2 (Bacheret al., 2005). Littleis known about the immunophenotypicfeatures of these AML. However, aberrantCD7 expressionhas been noted in some cases (Yamamotoet al., 2002). The clinical impactof +21 as a sole change is debatable;it has been associated with both intermediateand unfavorableprognosis(Corkset al., 1995; Grimwadeet al., 1998; Farag et al., 2002).

Trlsomy 22 Gain of chromosome22 is seen in 2-3% of cytogeneticallyabnormalAML, a frequency equivalentto 1 1 and 13. It is a relativelyfrequentaberrationin MDS ( I %) and ALL (5%);thus,trisomy22 is not specificfor AML. In the majority(90%)of AML with $22, it occurstogetherwith otherchanges,often numericalanomaliessuchas +8, 19, and +21. Trisomy22 is also the most common secondarychromosomechange to inv(16)(p13q22). In fact,Groiset al. (1 989) suggestedthatAML with +22 as the “sole” anomalyfrequently, perhapsalways, harborthis inversion.This has since been confirmedin several(Wongand

+

+

+

CHARACTERISTICCHROMOSOME ABNORMALITIESIN AML

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Kwong, 1999; Litmanovichet al., 2000; Mitterbaueret al., 2000), but not all (Langabeeret al., 1998) studies addressingthis issue. The moleculargenetic consequencesof +22 remainunknown. In contrastto several othertrisomiesin AML, namely +4, 1 1, 13, and +21, trisomy22 has, as yet, not been associated with a specific gene mutation. Isolatedtrisomy22 is morefrequentin men thanin women (SR 2.1) andis mainlyfound in young adults,with a medianage of 30 years. Although +22 has been reportedin several differentFAB types, a substantialproportionhas been AML M4, many with pronounced BM eosinophilia(Najfeldet al., 1986;Niemeyeret al., 1986; UKCCG, 1992a);these cases may have had an undetectedinv( 16). Althoughthe clinical impactof +22 as a sole change has not been addressedin any larger series, AML with gain of this chromosomeare groupedin the intermediateor in the unfavorablecytogeneticprognosisgroup(Grimwade et al., 1998; Byrd et al., 2002; Thiede et al., 2002).

+ +

Loss of the Y Chromosome Loss of the Y chromosome in BM cells is fairly common in elderly males without hematologicmalignancy(O’Riordanet al., 1970;Secker-Walker,1971), andshouldhence in most cases be acceptedas a normalage-relatedphenomenonwithoutany leukemogenic significance(Pierreand Hoagland,1972; Sandbergand Sakurai,1973; Abe et al., 1980; UKCCG, 1992~).Sometimes, however, -Y behaves like a born jide AML-associated abnormalityby disappearingin remission(Holmeset al., 1985b;Riskeet al., 1994). Wiktor et al. (2000) reportedthatthe percentagesof BM metaphaseswith loss of the Y chromosome differ between hematologically healthy controls and males with AML, with the latter displayinghigherlevels of Y loss. They suggestedthatthepresenceof > 75% cells with -Y probablyrepresentsan AML-associatedclone. However, whetherthis should be used in clinical decision making is debatable. In AML, -Y is seen in almost 10%of cytogeneticallyabnormalcases, most often (85%) togetherwith otherchanges,in particulart(8;21)(q22;q22).Lossof theY as a sole changeis, as expected, mainly found in middle-agedor elderly men, with a medianage of 60 years. Morphologically,AML with -Y show no FAB type preference.Auer rods have been reportedto be common (Billstrom et al., 1987; Keating et al., 1987). The outcome is generallyintermediate(Holmes et al., 1985b; Keatinget al., 1987; Schoutenet al., 1991; Slovak et al., 2000; Wiktoret al., 2000; Byrd et al., 2002).

Concluding Remarks on AML with Chromosome Changes A truly impressivenumberof AML-associatedabnormalities,often with clinically importantramifications,have been identifiedsince the adventof the variouschromosomebanding techniquesin the early 1970s. The morecommon ones were reviewed above and arealso listed in Table 5.2. However, many more are known. In fact, close to 2000 balanced aberrations,15%of them recurrent,have been describedin AML alone. These have been, and continue to be, of utmost importancein revealing genomic sites harboringgenes intimatelyinvolved in the leukemogenicprocess. For example, more than 130 different AML-associatedgene fusions have been identifiedand characterizedas a directresultof findingsbased on chromosomebandinganalyses.Thus, it might be temptingto conclude that we now have sufficient knowledge aboutgenetic changes in AML to understandthe development of this disease. We beg to differ; actually very little is known about

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translocationsand fusion genes in AML. Only approximately20% of AML are today associated with such aberrations.As recently reviewed and emphasizedby Mitelman et al. (2007), severalfundamentalquestionsremainto be answered,suchas why, how, when, and wherethe fusions arise.Ourpresentunderstandingof the underlyingmechanismsand pathogeneticconsequencesof the unbalancedchanges, which are more frequentthan the balancedones, is rudimentary.Much work remainsto be done, most of which is likely to entail the use of novel methods and techniques.Cytogenetics has remainedthe "gold standard"for the detection of chromosomalchanges in leukemia,developing as well as embracingnew andpowerfulinvestigatorytools, such as FISH,metaphase-basedand arraybased CGH, global expressionprofiling,and SNP arrays.All of these have been used to investigateand subdividethe largest cytogenetic AML subgroup,namely the one with a normalkaryotype.

AML WITH A NORMAL KARYOTYPE As seen in Table 5.1,20-30% of pediatricAML and 4650% of adultAML do not harbor anycytogeneticallyidentifiableabnormalities,thatis, they havenormalkaryotypes(NK). In some instances, the reasons are most likely technical, including division of only the nonneoplastic cells in culture or poor chromosome morphology precluding accurate analysis.As mentionedin the separatesections above, severaltranslocationsand inversion may easily go undetectedin suboptimalpreparations,namely inv(3)(q21q26),t(6;9)(p22; q34). t(6;I l)(q27;q23), t(9;1 l)(p2 I ;q23), t(l1;19)(q23;pl3), and inv(16>(p13q22). Other abnormalitiesare cytogeneticallycryptic, for examplet(5;1 I )(q35;p15). However,multicolor FISH analyses, includingthose using subtelomericprobes,have, with a few exceptions,not revealedanychromosomalabnormalitiesin NK-AML,stronglyindicatingthatthe above-mentionedtranslocationsrarely are present in such cases (Kearney,2006). Thus, other methodsare needed to identify the putativegenetic changes in NK-AML. Severalmetaphase-basedCGHinvestigations,whichcomparedto chromosomebanding analyses may be consideredthe next analyticalresolutionlevel, have been performedon NK-AML with only meagerresults.In fact, no changes were detected(Bentzet al., 1995; El-Rifai et al., 1997; Casas et al., 2004). In contrast,recent oligonucleotide-basedCGH studies, which have a much higher resolution, have disclosed genomic imbalancesin relatively large proportions(1540%) of NK-AML (Suela et al., 2007; Tyybikinoja et al., 2007). In addition,SNP arrayinvestigationshave revealedcrypticregionsof partial uniparentaldisomyin 10-20% of NK-AML.It has been shownthatthese regionsfrequently harbormutatedgenes that throughsomatic recombinationbecome homozygous, such as CEBPA,FLT3, andRUNXI mutations.SegmentalUPD may thereforebe seen as a second hit that removes the wild-type alleles (Fitzgibbon et a]., 2005; Gorletta et al., 2005; Raghavanet al., 2005). Thus, cases with NK are not universallynormalat the genome level. The variablenatureof the abnormalitiesdetected,both as regardsnumberof aberrationspercase andthe type of changes,thatis, deletion,gainor UPD, may partlyexplainthe clinicalheterogeneityin combinationwith the differentglobal gene expressionprofilesthat are observedin NK-AML (Bullingeret al., 2004; Valk et al., 2004; Mr6zeket al., 2007). Althoughgenomic and/orexpressionarraysmay be used in the nearfutureto subdivide NK-AML into prognosticallyimportantsubgroups,mutationanalysesof certaingenes are today performedin routineclinical practiceto classify such cases, as recentlyreviewedin detailby Mrcjzeket al. (2007). Forexample,FLT3ITD,butnotactivatingpointmutationsof

REFERENCES

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thisgene, has repeatedlybeen associatedwith an inferioroutcome,whereasthe presenceof

NPMl mutations, in the absence of FLT3 ITD or CEBPA mutations,correlatewith a favorableprognosisin NK-AML. In conclusion,fromgenerallyhaving been considereda ratheruninterestingkaryotypic AML subgroup,withoutnotableprognosticimpact,NK-AML hasemergedas an important subtypethat,based on molecularand expressionanalyses,can now be furtherdividedinto clinically relevantentities.

ACKNOWLEDGMENTS Financial support from the Swedish Cancer Society, the Swedish Childhood Cancer Foundation,the Swedish ResearchCouncil,LeukaemiaResearch,UK, and Kay Kendall LeukaemiaFundis gratefullyacknowledged.We arealso very gratefulto LindaMagnusson for help with all the figures.

REFERENCES Aatola M, ArmstrongE, Teerenhovi L, BorgstromGH (1 992): Clinical significance of the del(20q) chromosomein hematologic disorders. Cancer Genet Cytogenet 6275-80. Abe S, SandbergAA (1979): Chromosomesand causation of human cancer and leukemia. XXXII. Unusual features of Phl -positive acute myeloblastic leukemia (AML), including a review of the literature.Cancer 43:2352-2364. Abe S, Golomb HM, Rowley JD,Mitelman F,SandbergAA ( 1 980): Chromosomesand causationof humancancerandleukemia. XXXV. The missing Y in acutenon-lymphocyticleukemia (ANLL). Cuncer 45:84-90. AdriaansenHJ, te Boekhorst PAW, HagemeijerAM, Van Der Schoot CE. Delwel HR, Van Dongen JJM (1 993): Acute myeloid leukemia M4 with bone marroweosinophilia (M4Eo) and inv( 16) (PI 3q22) exhibits a specific immunophenotypewith CD2 expression. Blood 8 1 :3043-305 1. Ageberg M, Drott K, Olofsson T, Gullberg U, LindmarkA (2008): Identificationof a novel and myeloid specific role of theleukemia-associatedfusion proteinDEK-NUP214leadingto increased protein synthesis. Genes Chromosomes Cancer 47:276287. AhujaHG. Felix CA, Aplan PD ( 1999): The t( I 1;2O)(pl5;qlI) chromosomaltranslocationassociated with therapy-related myelodysplastic syndrome results in an NUP98-TOP1 fusion. Blood 943258-3261. AkahoshiM, Oshimi K,Mizoguchi H, OkadaM, EnomotoY, WatanabeY ( I 987): Myeloproliferative disordersterminatingin acute megakaryoblasticleukemia with chromosome 3q26 abnormality. Cancer 60:2654-266 I . Albin M, BjorkJ, WelinderH, TinnerbergH, MauritzsonN, JohanssonB, BillstromR, StrombergU, Mikoczy Z, AhlgrenT,Nilsson P-G, MitelmanF, HagmarL (2000): Acute myeloid leukemiaand clonal chromosome aberrationsin relation to past exposure to organic solvents. Scund J Work Environ Health 26:482491. AlimenaG,Dallapiccola B, De CuiaMR,GalloE, GastaldiR, NanniM, FranchiA, MandelliF ( 1984): Cytogenetic findings in acute promyelocytic leukemia. A reportof 25 cases. Scund J Haematol 33:135-143. Alitalo T, WillardHF, de la Chapelle A (1989): Determinationof the breakpointsof 1;7translocations in myelodysplasticsyndromeby in situ hybridizationusing chromosome-specifica satellite DNA from humanchromosomes 1 and 7. Cytogenet Cell Genet 5049-53.

100

ACUTE MYELOID LEUKEMIA

Altucci L, Leibowitz MD, Ogilvie KM, de Lera AR, Gronemeyer H (2007): RAR and RXR modulationin cancer and metabolic disease. Nut Rev Drug Discov 6:793-8 10. AndersenMK, ChristiansenDH, KirchhoffM, Pedersen-BjergaardJ (2001): Duplicationor amplification of chromosome band llq23, including the unrearrangedM U gene, is a recurrent abnormalityin therapy-relatedMDS and AML, and is closely related to mutationof the TP53 gene and to previous therapy with alkylating agents. Genes ChromosomesCancer 31:3341. Andersen MK, LarsonRA, MauritzsonN, SchnittgerS, JhanwarSC, Pedersen-BjergaardJ (2002): Balanced chromosome abnormalitiesinv(16) and t( 15;17) in therapy-relatedmyelodysplastic syndromes and acute leukemia: repon from an internationalworkshop. Genes Chromosomes Cancer 33395400. AndreassonP, JohanssonB, BillstromR, GarwiczS, MitelmanF, Hoglund M ( 1998):Fluorescencein situ hybridizationanalyses of hematologic malignancies reveal frequentcytogenetically unrecognized 12p rearrangements.Leukemia 12390-400. AplanPD (2006):Chromosomaltranslocationsinvolving the MUgene: molecularmechanisms.DNA repair5:1265-1 272. Appelbaum FR, GundackerH, Head DR, Slovak ML, Willman CL, Godwin JE, Anderson JE, PetersdorfSH (2006a): Age and acute myeloid leukemia. Blood 107:3481-3485. Appelbaum FR, Kopecky KJ, Tallman MS, Slovak ML, GundackerHM, Kim HT, Dewald GW, KantarjianHM, Pierce SR, Estey EH (2006b): The clinical spectrum of adult acute myeloid leukaemia associated with core binding factor translocations.Br J Huematol 135:165-173. Arai Y, HosodaF, KobayashiH,Arai K, HayashiY, KamadaN, KanekoY,Ohki M ( 1997):The inv(1 I ) (p 15q22)chromosometranslocationof de novo and therapy-relatedmyeloid malignanciesresults in fusion of the nucleoporingene, NUP98, with the putativeRNA helicase gene, DDXIO. Blood 89:3936-3944. Arber DA, Chang KL, Lyda MH, Bedell V, SpielbergerR, Slovak ML (2003): Detection of NPM/ MLFI fusion in t(3;5)-positive acute myeloid leukemia and myelodysplasia. Hum Pathol 342309-813.

ArchimbaudE, CharrinC, MagaudJ-P,CamposL, ThomasX, FiereD, RimokhR ( 1998):Clinical and biological characteristicsof adult de novo and secondary acute myeloid leukemia with balanced 1 lq23 chromosomalanomaly or MLL gene rearrangementcomparedto cases with unbalanced I lq23 anomaly: confirmation of the existence of different entities with 1 lq23 breakpoint. Leukemia 1225-33. ArmandP, Kim HT, DeAngelo DJ, Ho VT, CutlerCS,Stone RM,Ritz J, Alyea EP, AntinJH,Soiffer RJ (2007): Impactof cytogenetics on outcome of de novo and therapy-relatedAML and MDS after allogeneic transplantation.Biol Blood MarrowTransplant1 3:655-664. ArnoldJA, Ranson SA, Abdalla SH (1999): Azathioprine-associatedacute myeloid leukaemiawith trilineage dysplasia and complex karyotype:a case reportand review of the literature.Clin Lab Haemuto121:289-292. ArnouldC, PhilippeC, BourdonV,GregoireMJ, BergerR, JonveauxP (1999): The signal transducer and activatorof transcriptionSTAT5bgene is a new partnerof retinoic acid receptora in acute promyelocytic-like leukaemia. Hum Mol Genet 8:I741-I 749. AuerbachAD, Allen RG (1991): Leukemiaand preleukemiain Fanconianemiapatients.A review of the literatureand reportof the InternationalFanconi Anemia Registry. CancerGenet Cyfogenet 51 :1-12. Ayton PM, Cleary ML (2001): Molecular mechanismsof leukemogenesismediated by MLL fusion proteins. Oncogene 20:5695-5707. BacherU, KernW, SchnittgerS, HiddemannW, Schoch C, HaferlachT (2005): Furthercorrelationsof morphologyaccording to FAB and WHO classification to cytogenetics in de novo acute myeloid leukemia: a study on 2,235 patients.Ann Hemafol84:785-791.

REFERENCES

101

Baer MR, Bloomfield CD (1 992): Trisomy 13 in acute leukemia.Leuk Lymphoma 7: 1-6. Baer MR, StewartCC, Lawrence D, ArthurDC,Mrozek K, StroutMP, Davey FR, Schiffer CA, Bloomfield CD (1998): Acute myeloid leukemia with 1lq23 translocations:myelomonocytic immunophenotypeby multiparameterflow cytometry.Leukemia 1 2 317-325. Ball ED, Davis RB. GriffinJD, MayerRJ,Davey FR,ArthurDC,Wurster-KillD, Noll W,Elghetany MT,Allen SL,Rai K, Lee EJ,SchifferCA, BloomfieldCD (1991): Prognosticvalueof lymphocyte surfacemarkersin acute myeloid leukemia.Blood 77:2242-2250. BarangerL, GardembasM, HillionJ, FoussardC, IfrahN, Boasson M, BergerR (1 993): Rearrangements of the RAM and PML genes in a cytogenetic variantof acute promyelocyticleukemia. Genes Chromosomes Cancer 6:I 18-120. BarbaricD, Alonzo TA, GerbingRB, MeshinchiS, HeeremaNA, BarnardDR, LangeBJ,WoodsWG, Arceci RJ,SmithFO (2007): Minimallydifferentiatedacutemyeloid leukemia(FABAh4L-MO)is associatedwith an adverseoutcome in children:a reportfrom the Children’sOncology Group, studiesCCG-2891 and CCG-2961. Blood 109:2314-2321. BarboutiA, StankiewiczP, NusbaumC, CuomoC, Cook A, HoglundM, JohanssonB, HagemeijerA, ParkSS, MitelmanF, LupskiJR, FioretosT (2004): The breakpointregion of the most common isochromosome,i( 17q). in humanneoplasiais characterizedby a complex genomic architecture with large, palindromic,low-copy repeats.Am J Hum Genet 74:l-10. Barjestehvan Waalwijkvan Doom-KhosrovaniS, ErpelinckC, van PuttenWL, Valk PJM, van der Poel-vande LuytgaardeS, Hack R, SlaterR, Smit EME, Beverloo HB, Verhoef G, VerdonckLF, OssenkoppeleGJ, Sonneveld P, de Greef GE, Lowenberg B, Delwel R (2003): High EVII expression predicts poor survival in acute myeloid leukemia: a study of 319 de novo AML patients.Blood 101:837-845. BaruchelA, Daniel M-T, SchaisonG, Berger R (1991): Nonrandomt(1;22)(p12-p13;q13)in acute megakaryocyticmalignantproliferation.Cancer Genet Cytogenet 54:239-243. BaseckeJ, WhelanJT,GriesingerF, BertrandFE(2006): TheMLLpartialtandemduplicationin acute myeloid leukaemia.Br J Haematol 135438449. BecherR, CarbonellF,BartramCR ( 1990):Isochromosome17qin Phl-negativeleukemia:a clinical, cytogenetic,and molecularstudy.Blood 75: 1679-1 683. Beghini A, RipamontiCB, CastorinaP, PezzettiL. Doneda L, CairoliR,MorraE, LarizzaL (2000): Trisomy4 leadingto duplicationof a mutatedKITallelein acutemyeloidleukemiawith mastcell involvement.Cancer Genet Cytogenet I19:26-31. BeghiniA, RipamontiCB, CairoliR,CazzanigaG, ColapietroP, Elice F, NadaliG,Grill0 G, Haas OA, Biondi A, MorraE, LarizzaL (2004): KITactivatingmutations:incidencein adultand pediatric acute myeloid leukemia, and identificationof an internaltandem duplication.Haematofogica 89:920-925. Bench AJ, Nacheva EP, Hood TL, Holden JL, French L, Swanton S, Champion KM, Li .I, WhittakerP, StavridesG,HuntAR, HuntlyBJP, CampbellW,Bentley DR, Deloukas P, Green AR (2000): Chromosome 20 deletions in myeloid malignancies: reductionof the common deleted region, generation of a PACA3AC contig and identification of candidate genes. Oncogene 19:3902-3913. BCne MC, Bernier M, CasasnovasRO. Castoldi G, DoekharanD, van der Holt B, Knapp W, Lemez P, Ludwig W-D, MatutesE, Orfao A, Schoch C, SperlingC, van? Veer MB (2001): Acute myeloid leukaemia MO: haematological, immunophenotypicand cytogenetic characteristics and their prognostic significance: an analysis in 241 patients. Br J Haematol 113:737-745. Bennett JM, Catovsky D, Daniel MT, FlandrinG, Galton DAG, GralnickHR, Sultan C (1976): Proposals for the classificationof the acute leukaemias.French-American-British (FAB) cooperativegroup. Br J Haematol33:451 4 5 8 .

102

ACUTE MYELOID LEUKEMIA

BennettJM, Catovsky D, Daniel MT, FlandrinG, Galton DAG, GralnickHR, Sultan C (1985a): CriteriaForthe diagnosisof acuteleukemiaof megakaryocytelineage(M7).A reportof theFrenchAmerican-BritishCooperativeGroup.Ann Intern Med 1 0 3 : 4 M 2 . Bennett JM, Catovsky D, Daniel MT, FlandrinG , Galton DAG, GralnickHR, Sultan C (1985b): Proposed revised criteria for the classification of acute myeloid leukemia. A report of the French-American-BritishCooperativeGroup.Ann Intern Med 103:620-625. Bennetl JM, Catovsky D, Daniel MT, FlandrinG, Galton DAG, Gralnick HR, Sultan C (1991): Proposalfor therecognitionof minimallydifferentiatedacutemyeloid leukaemia(AML-MO).Br J HU~~TUI~OI 78~325-329. Bentz M, DohnerH, HuckK, SchutzB, GanserA, JoosS , duManoirS, LichterP (1995): Comparative genomic hybridizationin the investigationof myeloid leukemias.Genes Chromosomes Cancer 12:193-200. BergerR ( 1975): Translocationt( I I ;20) et polyglobulie primitive.N o w Presse Med 4: 1972. Berger R, Bernheim A, Weh H-J, Daniel M-T, FlandrinG (1980): Cytogenetic studies on acute monocyticleukemia.Leuk Res 4: 119-1 27. Berger R, Bemheim A, Daniel MT, Valensi F, FlandrinG (1981): t(15;17) translocationin acute promyelocyticleukaemia(M3) and cytological “M3-variant.”Nouv Rev Fr Hematol23:27-38. BergerR, Den6 J, Le Coniat M,H L M J, RomanaPS, JonveauxP ( 1995): Inversion-associated translocationsin acutemyelomonocyticleukemiawith eosinophilia.Genes Chromosomes Cancer 12:5842. BergerR, Le ConiatM, LacroniqueV, Daniel M-T, LessardM, BerthouC, MarynenP, Bernard0 (1997): Chromosome abnormalitiesof the short arm of chromosome 12 in hematopoietic malignancies: a report including three novel translocationsinvolving the TELETV6 gene. Leukemia 11:1400-1403. Bernstein R, Pinto MR, Behr A, Mendelow B (1982): Chromosome3 abnormalitiesin acute nonlymphocyticleukemia(ANLL) with abnormalthrombopoiesis:reportof three patientswith a “new” inversionanomalyand a furthercase of homologoustranslocation.Blood 60:613417. BemsteinR, PintoMR, SpectorI, MacdougallLG (1987): A unique&I6 translocationin two infants with poorly differentiatedmonoblasticleukemia.Cancer Genet Cytogenet 24:2 13-220. BernsteinJ, Dastugue N, Haas OA, HarbottJ, HeeremaNA, HuretJL, Landman-Parker J, LeBeau MM, LeonardC, Mann G, Pages MP, Perot C, Pirc-DanoewinataH, RoitzheimB, Rubin CM, Slociak M, Viguie F (2000): Nineteen cases of the t( 1;22)(p13;q13)acute rnegakaryoblastic leukaemiaof infantskhildrenanda reviewof 39 cases:reportFroma t( 1;22)studygroup.Leukemia 14:216-218. BeverlooHB, Le ConiatM, WijsmanJ, LillingtonDM, Bernard0,de Klein A, vanWeringE, Welborn J, Young BD, HagemeijerA. BergerR (1995): Breakpointheterogeneityin t( 10;11) translocation in AML-M4/M5 resulting in Fusion of AFlO and M U is resolved by fluorescent in situ hybridizationanalysis. Cancer Res 55:42204224. Beverloo HB, PanagopoulosI, IsakssonM, van WeringE, van DrunenE, de Klein A, JohanssonB, SlaterR (2001): Fusionof the homeoboxgene H U B 9 andthe Em6 gene in infantacutemyeloid leukemiaswith the t(7;12)(q36;p13).Cancer Res 615374-5377. BiggerstaffJS,Liu W, Slovak ML, BobadillaD, BryantE, GlotzbachC, ShafferLG (2006): A dualcolorFISHassaydistinguishesbetweenELLandMLLTI(ENL)gene rearrangements in t( 1 1; 19)positive acute leukemia.Leukemia 20:2046-2050. Bilhou-NaberaC, Lesesve J-F,MaritG, LafageM, DastugueN, GoullinB, ArnouletC, StoppaA-M, Huguet F, Attal M,LacombeF, BroustetA, ReiffersJ, BernardP (1994): Trisomy 11 in acute myeloid leukemia:ten cases. kukemia 8:2240-224 I. BillstromR, Nilsson P-G,MitelmanF ( 1 987):Characteristic patternsof chromosomeabnormalitiesin acute myeloid leukemiawith Auer rods. Cancer Genet Cytogenet 28:191-199.

REFERENCES

103

Billstrom R, Heim S, KristofferssonU, MandahlN, Mitelman F (1990): Structuralchromosomal abnormalitiesof 3q in myelodysplastic syndrome/acutemyeloid leukaemia with Sweet’s syndrome. Eur J HaematoI45:150152. B i l l s t r h R, JohanssonB, Fioretos T, Garwicz S, Malm C, Zettervall 0, Mitelman F (1997): Poor survival in t(8;2 1 )(q22;q22)-associated acute myeloid leukaemia with leukocytosis. Eur J HaeMtol59:47-52. Billstrom R, Ahlgren T,BCkissy AN, Malm C, Olofsson T, Hoglund M, Mitelman F, JohanssonB (2002): Acute myeloid leukemiawith inv(16)(p13q22): involvementof cervical lymph nodes and tonsils is common and may be a negative prognostic sign. Am J Hemato17I :15- 19. Bitter MA, Neilly ME, Le Beau MM, PearsonMG,Rowley JD (1985): Rearrangementsof chromosome 3 involving bands 3q2L and 3q26 are associatedwith normalor elevated platelet counts in acute nonlymphocyticleukemia. Blood 66: 1362-1370. Blanco JG, DervieuxT,Edick MJ, MehtaPK, RubnitzJE,ShurtleffS, RaimondiSC, Behm FG, Pui CH, Relling MV (2001): Molecularemergenceof acutemyeloid leukemiaduringtreatmentfor acute lymphoblastic leukemia. Proc Nut1 Acad Sci USA 98:10338-10343. Block AW, Carroll AJ, HagemeijerA, Michaux L, van Lorn K, Olney HJ, Baer MR (2002): Rare recurringbalancedchromosomeabnormalitiesin therapy-relatedmyelodysplasticsyndromesand acute leukemia:reportfrom an internationalworkshop.Genes ChromosomesCancer 33:401412. BloomfieldCD, PetersonLC, YunisJJ,BrunningRD (1977): The Philadelphiachromosome(Phl) in adultspresentingwith acuteleukaemia:a comparisonof Phl and Phl - patients.Br JHuemafol 36:347-358. Bloomfield CD, GarsonOM, Volin L, KnuutilaS, de la ChapelleA ( 1985):t( I ;3)(p36;q21) in acute nonlymphocyticleukemia:anew cytogenetic-clinicopathologicassociation.Blood 66:1409-1 4 13. Bloomfield CD, Lawrence D, Byrd JC,CarrollA, Pettenati MJ, TantravahiR, Patil SR, Davey FR, Berg DT, Schiffer CA, ArthurDC, Mayer RJ (1998): Frequencyof prolongedremission duration afterhigh-dose cytarabineintensificationin acutemyeloid leukemiavariesby cytogenetic subtype. Cancer Res 58:41734179. Bloomfield CD, ArcherKJ,MrozekK, Lillington DM, KanekoY,HeadDR, Dal Cin P, RaimondiSC (2002): 1 lq23 balancedchromosomeaberrationsin treatment-relatedmyelodysplasticsyndromes and acute leukemia: report from an internationai workshop. Genes Chromosomes Cancer 33:362-378. Blum W, Mrozek K, Ruppert AS, Carroll AJ, Rao KW, Pettenati MJ, Anastasi J, Larson RA, Bloomfield CD (2004): Adult denovo acutemyeloid leukemiawith t(6;ll )(q27;q23):resultsfrom Cancerand LeukemiaGroupB Study 8461 and review of the literature.Cancer 101:1420- 1427. Boer JM, van DeursenJMA, CroesW, FransenJAM, GrosveldGC (1997a):The nucleoporinCAN/ Nup214 binds to both the cytoplasmicandthe nucleoplasmicsides of the nuclearporecomplex in overexpressingcells. Exp Cell Res 232: 182-1 85. Boer J, Mahmoud H, Raimondi S, Grosveld G, Krance R (1997b): Loss of the DEK-CAN fusion transcriptin a child with t(6;9) acute myeloid leukemia following chemotherapyand allogeneic bone marrow transplantation.Leukemia I 1 :299-300. BohlanderSK (2005): ETV6 a versatile player in leukemogenesis. Semin Cancer Biol15: 162-174. BorgstromGH, TeerenhoviL, Vuopio P, de la ChapelleA, Van Den BergheH, BrandtL, GolombHM, Louwagie A, MitelmanF, Rowley JD, SandbergAA (1 980):Clinical implicationsof monosomy 7 in acute nonlymphocyticleukemia. Cancer Genet Cytogenet 2: 1 15-1 26. Borgstrom GH, Vuopio P, de la Chapelle A (1982): Abnormalities of chromosome No. 17 in myeloproliferativedisorders.Cancer Genet Cytogenet 5 :123-1 35. BorkhardtA, Bojesen S, Haas OA, Fuchs U, BartelheimerD, Loncarevic IF, Bohle RM, HarbottJ, Repp R, Jaeger U,ViehmannS, Henn T,KorthP,ScharrD, LampertF (2000): The humanGRAF gene is fused to M U in a uniquet(5; 1 I )(q3 l;q23) and both alleles are disruptedin three cases of

+

104

ACUTE MYELOID LEUKEMIA

myelodysplastic syndromelacutemyeloid leukemia with a deletion 5q. Proc Natl Acad Sci USA 97:9168-9173. BorkhardtA, Teigler-Schlegel A, Fuchs U, Keller C , Konig M, HarbottJ, Haas OA (2001): An ins (X;1 1 )(q24;q23)fuses the MLL andthe Septin 6lKlAAO128gene in an infantwith AML-M2. Genes Chromosomes Cancer 32:82-88. Borrow J, GoddardAD, Sheer D, Solomon E (1990): Molecular analysis of acute promyelocytic leukemia breakpointcluster region on chromosome 17. Science 249: 1577-1 580. Bormw J, GoddardAD, GibbonsB, Katz F, Swirsky D, FioretosT, D u b 1, Winfield DA, KingstonJ, HagemeijerA, Rees JKH,ListerTA, SolomonE ( 1992):Diagnosisof acutepromyelocyticleukaemia by RT-PCR:detectionof PML-RARA andRAM-PML fusiontranscripts.Br JHaemato182:529-540. BorrowJ, ShearmanAM, StantonVPJr,BecherR, CollinsT,WilliamsAJ, D U GI, Katz F, Kwong YL, Morris C, Ohyashiki K, Toyama K, Rowley J, Housman DE (1996a): The t(7:ll)(p15;p15) translocation in acute myeloid leukaemia fuses the genes for nucleoporin NUP98 and class I homeoproteinHOXA9. Nat Genet 12:159- 167. Borrow J, Stanton VP Jr. AndresenJM, Becher R, Behm FG,ChagantiRSK, Civin C1, Disteche C, Dub151. FrischaufAM, HorsmanD. Mitelman F,Volinia S,WatmoreAE, Housman DE (1996b): The translocation t(8;I6)(p 1 I :p13)of acute myeloid leukaemiafuses a putativeacetyltransferaseto the CREB-bindingprotein. Nat Genet 14:33-4 1. Bram S , Swolin B, RodjerS, StockelbergD, Ogard1, Back H (2003): Is monosomy 5 an uncommon aberration?Fluorescence in situ hybridizationreveals translocationsand deletions in myelodysplastic syndromesor acute myelocytic leukemia. Cancer Genef Cytogenet 142:107-1 14. Breitman TR, Collins SJ, Keene BR (1981): Terminal differentiation of human prornyelocytic leukemic cells in primaryculture in response to retinoic acid. Bfood 57: IOOO-1004. BrownJ, JawadM, Twigg SRF, SaracogluK, SauerbreyA, ThomasAE, Eils R, HarbottJ, Keamey L (2002): A cryptic t(5;I l)(q35;p15.5) in 2 children with acute rnyeloidleukemia with apparently normal karyotypes, identified by a multiplex fluorescence in situ hybridizationtelomere assay. Blood 99:252&253 I . BrunningRD, Matutes E, Harris NL, FlandrinG, VardimanJ, Bennett J, Head D (2001): Acute Myeloid Leukaemias. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. Jaffe ES, HarrisNL, Stein H, VardimanJW, editors. IARC Press: Lyon, France,pp 77-80. Buijs A, Bruin M (2007): Fusion of FlPlLf and RAM as a resultof a novel t(4; 17)(q12;q21 ) in a case of juvenile myelomonocytic leukemia. kukemiu 21: 1 104-1 108. Bullinger L, Dohner K, Bair E, FrohlingS, Schlenk RF, TibshiraniR, Dohner H, Pollack JR (2004): Use of gene-expressionprofilingto identify prognosticsubclassesin adultacutemyeloid leukemia. NEnglJMed350:1605-1616. BumettAK, Wheatley K, Goldstone AH, Stevens RF, Hann IM, Rees JHK, HarrisonG (2002): The value of allogeneic bone marrowtransplantin patients with acute rnyeloidleukaemiaat differing risk of relapse: resultsof the UK MRC AML 10 trial. Br J Haematol 1 18:385-40. Busson-LeConiat M, Salomon-NguyenF, Hillion J, BernardOA. BergerR (1999):MLL-AFlqfusion resulting from t( I ;1 I) in acute leukemia. k k e m i a 13:302-306. ByrdJC, Weiss RB, ArthurDC, LawrenceD, Baer MR, Davey F,TrikhaES, CarrollAJ, TantravahiR, QumsiyehM, PatilSR, Moore JO, MayerRJ,SchifferCA, BloomfieldCD (1 997): Extramedullary leukemia adversely affects hematologic complete remission rate and overall survival in patients with t(8;21)(q22;q22): results from Cancerand Leukemia Group B 8461. J Clin Oncol 15:466-475. ByrdJC, LawrenceD, ArthurDC, PettenatiMJ, TantravahiR,Qumsiyeh M, StarnbergJ, Davey FR, SchifferCA, Bloomfield CD (1998): Patientswith isolated trisomy8 in acute myeloid leukemiaare not curedwith cytarabine-basedchemotherapy:resultsfrom CancerandLeukemiaGroupB 846 I . Clin Cancer Res 4: 1235- I24 I.

REFERENCES

105

ByrdJC,DodgeRK,CarrollA, BaerMR,EdwardsC, StambergJ, QumsiyehM, MooreJO,MayerRJ, Davey F, SchifferCA, Bloomfield CD (1999): Patientswith t(8;21)(q22;q22)and acute myeloid leukemia have superiorfailure-freeand overall survival when repetitivecycles of high-dose cytarabineare administered.J Clin Oncol I7:3767-3775. ByrdJC,MnjzekK, Dodge RK,CarrollAJ,EdwardsCG,ArthurDC, PettenatiMJ, PatilSR,Rao KW, WatsonMS, KoduruPR, MooreJO, Stone RM, MayerRJ, FeldmanEJ, Davey FR, SchifferCA, Larson RA, Bloomfield CD (2002): Pretreatmentcytogenetic abnormalitiesare predictiveof inductionsuccess, cumulativeincidenceof relapse,and overall survivalin adultpatientswith de novo acuternyeloidleukemia:resultsfromCancerand LeukemiaGroupB (CALGB846 I). Blood 100.43254336. CaligiuriMA, SchichmanSA, StroutMP,MrozekK, BaerMR, FrankelSR,BarcosM, HerzigGP,Croce of theA L L I genein acutemyeloidleukemia CM,BloomfieldCD ( 1994):Molecularrearrangement withoutcytogeneticevidence of I I q23 chromosomaltranslocations.Cancer Res 54:370-373. CaligiuriMA, StroutMP, Oberkircher AR, Yu F, de la ChapelleA, BloomfieldCD (1997): The partial tandemduplicationof ALL1 in acutemyeloid leukemiawith normalcytogeneticsor trisomyI 1 is restrictedto one chromosome.Proc Nut1 Acad Sci USA 94:3899-3902. CallensC, ChevretS, CayuelaJ-M,CassinatB, RaffouxE, de BottonS, ThomasX, GuerciA, Fegueux N, PigneuxA, StoppaAM, LamyT, Rigal-HuguetF, Vekhoff A, Meyer-MonardS.FerrandA, Sanz M, ChomienneC, Fenaux P, DombretH (2005): Prognosticimplicationof FLT3 and Rar gene mutationsin patientswith acute promyelocyticleukemia (APL): a retrospectivestudy from the EuropeanAPL group. Leukemia 19:1l53-1l60. Camos M, Esteve J, JaresP, ColomerD, RozmanM, VillamorN, Costa D, Cani6 A, Nomdedeu J, MontserratE, Campo E (2006): Gene expression profiling of acute myeloid leukemia with translocationt(8;16)(plI ;p13) andMYST3-CREBBP rearrangement revealsa distinctivesignature with a specific patternof HOX gene expression.Cancer Res 66:6947-6954. Campbell W,Garson OM (1994): The prognostic significance of deletion of the long arm of chromosome20 in myeloid disorders.Leukemia 8:67-7 I. CampbellLJ. Challis J, Fok T, GarsonOM (1991): Chromosome16 abnormalitiesassociatedwith myeloid malignancies.Genes Chromosomes Cancer 3:554 I. Carlson KM, Vignon C, BohlanderS , Martinez-ClimentJA, Le Beau MM. Rowley JD (2000): Identificationand molecularcharacterizationof CALM/AFIO fusion productsin T cell acute lymphoblasticleukemiaand acute rnyeloid leukemia.Leukemia 14:100-104. CarrollA, CivinC, SchneiderN, DahlG,PappoA, BowmanP, EmamiA, GrossS, AlvaradoC, Phillips C, KrischerJ, CristW, Head D, GresikM, RavindranathY, WeinsteinH (1991): The t( 1;22)(pl3; q13) is nonrandomand restrictedto infantswith acute megakaryoblasticleukemia:a Pediatric Oncology Groupstudy. Blood 78:748-752. CarterM, KalwinskyDK, MirroJ Jr,Behm FG, Head D, HuddlestonTF, RaimondiSC ( 1991):The t (1 0;l I)(p 14;q21) translocationin three children with acute myeloblastic leukemia. Leukemia 5156 1-565. Casas S, Aventin A, FuentesF,Vallespj T,GranadaI, Cani6A, Angel Martinez-Climent JA, Sol6 F, Teixid6M, BernuCsM, DuarteJ, HemhdezJM,BrunetS, DolorsColl M, SierraJ (2004): Genetic diagnosis by comparativegenomic hybridizationin adult de novo acute myelmytic leukemia. Cancer Genet Cytogenet 153:16-25. CasasnovasRO, Campos L, MugneretF, CharrinC, Btn6 MC, GarandR, FavreM, SartiauxC, ChaumarelI, BernierM, FaureG, Solary E ( I 998): lmmunophenotypicpatternsand cytogenetic anomalies in acute non-lymphoblasticleukemia subtypes:a prospectivestudy of 432 patients. Leukemia 12:34-43. Casillas JN, Woods WG, Hunger SP, McGavran L. Alonzo TA, Feig SA (2003): Prognostic implicationsoft( 1O;l I) translocationsin childhoodacute myelogenousleukemia:a reportfrom the Children’sCancerGroup.J Pediatr Hematol Onco125:594-600.

106

ACUTE MYELOID LEUKEMIA

CastaigneS, BergerR, Jolly V, Daniel MT, BernheimA, MartyM, Degos L, FlandrinG (1984): Promyelocyticblast crisis of chronicmyelocytic leukemia with both t(9;22) and t(l5;17) in M3 cells. Cancer54:2409-2413. CastaigneS, ChomienneC, Daniel MT, BalleriniP, Berger R, Fenaux P, Degos L (1 990): All-trans retinoic acid as a differentiationtherapy for acute promyelocyticleukemia. 1. Clinical results. Blood 76:1704- 1709. Caudell D, Aplan PD (2008): The role of CALM-AFIO gene fusion in acute leukemia. Leukemia 22:678-685. CerveiraN. CorreiaC, D6riaS, BizarroS, RochaP, ComesP, TorresL, NortonL, BorgesBS, Castedo S, TeixeiraMR (2003): Frequencyof NUP98-NSDI fusion transcriptin childhoodacutemyeloid leukaemia.Leukemia 17:2244-2247. CerveiraN, CorreiaC, Bizam, S, PintoC, Lisboa S, Mariz JM, MarquesM, Teixeira MR (2006): SEPZ2 is a new fusionpartnerof M U in acutemyeloid leukemiawith t(2;I l)(q37;q23).Oncogene 25:6147-6152. ChangH, BrandweinJ. Yi Q-L, Chun K, PattersonB, Brien B (2004): Extramedullaryinfiltratesof AML are associatedwith CD56 expression, 1 lq23 abnormalitiesand inferiorclinical outcome Leuk Res28:1007-1011. ChaplinT, Bernard0,Beverloo HB, SahaV, HagemeijerA, BergerR, Young BD (1995):Thet( 1O;ll) translocationin acutemyeloid leukemia(M5) consistentlyfusesthe leucinezippermotif of A F l O onto the HRX gene. Blood 86:2073-2076. ChaninC, BelhabriA, Treille-RitouetD. TheuilG, MagaudJ-P,FiereD, ThomasX (2002): Structural rearrangements of chromosome3 in 57 patientswith acute myeloid leukemia:clinical, hematological and cytogeneticfeatures.HematolJ 3:21-31. ChauffailleMde LLF,FerminoFA, PellosoLAF,SilvaMRR,BordinJO,YamamotoM (2003): t(4;12) (91 l;p13):a rare-chromosomal translocationin acutemyeloid leukemia.Leuk Res 27:363-366. Chen SJ, FlandrinG, Daniel M-T, Valensi F, BarangerL, GrauszD, BernheimA, Chen Z, Sigaux F, Berger R ( 1988): Philadelphia-positiveacute leukemia:lineage promiscuity and inconsistently rearrangedbreakpointclusterregion. Leukemia2 2 6 1-273. ChenZ,BrandNJ,ChenA,ChenS-J,TongJ-H,WangZ-Y,WaxmanS,ZelentA(1993):Fusionbetween a novel Kriippel-likezinc fingergene and the retinoicacid receptor-alpha locus due to a variantt (1 1;17) translocationassociatedwith acutepromyelocyticleukaemia.EMBO J 12:1 161-1 167. Chen Z, Guidez F, Rousselot P, Agadir A, Chen S-J, Wang Z-Y,Degos L, Zelent A, WaxmanS, ChomienneC ( 1994): PLZF-RARafusion proteinsgeneratedfrom the variantt( 11 ;17)(q23;q21) translocationin acute promyelocyticleukemiainhibit ligand-dependenttransactivationof wildtype retinoicacid receptors.ProcNatl Acad Sci USA 9 I :1 178-1 182. CherifD, Bernard0, PaulienS, JamesMR, Le PaslierD, BergerR (1994): Hunting1 lq23 deletions with fluorescence in situ hybridization(FISH). Leukemia8578-586. CiminoG, Moir DT, Canaani0,WilliamsK, CristWM, KatzavS, CannizzaroL, LangeB, Nowell PC, CroceCM,CanaaniE(1991):CloningofALLI,thelocusinvolvedinleukemiaswiththe t(4;l lKq21; CancerRes51:6712-6714. q23),t(9;11)(p22;q23),andt(11;19)(q23;p13)chromosometranslocations. CiminoG, Lo COCO F, Biondi A, Elia L, Lucian0A, CroceCM, MaseraG,Mandelli F, CanaaniE (1993): ALL-I gene at chromosome I lq23 is consistently altered in acute leukemia of early infancy. Blood 82:544-546. ClaxtonDF, Liu P, Hsu HB, MarltonP, HesterJ, Collins F, Deisseroth AB, Rowley JD, SicilianoMJ (1994): Detection of fusion transcriptsgeneratedby the inversion 16 chromosome in acute myelogenous leukemia. Blood 83:1750-1 756. Cools J, Bilhou-NaberaC. WlodarskaI, CabrolC, TalmantP, BernardP, HagemeijerA, MarynenP (1999): Fusion of a novel gene, BTL, to Em6 in acutemyeloid leukemiaswith a t(4;12)(q1 1-9 12; pl3). Blood 94:1820-1 824.

REFERENCES

107

Cools I, Mentens N, Odero MD, Peeters P, Wlodarska1, Delforge M, HagemeijerA, MarynenP (2002): Evidence for position effects as a variantEW6-mediatedleukemogenicmechanismin myeloid leukemiaswith a t(4;12)(ql l-q12;p13) or t(5;12)(q31;p13).Blood 99:1776-1784. Corey SJ, LockerJ, OliveriDR, Shekhter-LevinS, RednerRL,PenchanskyL, Gollin SM (1994): A non-classicaltranslocationinvolving 17q12 (retinoicacid receptoralpha)in acutepromyelocytic leukemia(APML)with atypicalfeatures.Leukemia 8:1350-1353. CorralJ, ForsterA. ThompsonS, LampertF, KanekoY,SlaterR, KroesWG, van der Schoot CE, Ludwig W-D, KarpasA, Pocock C, CotterF, RabbittsTH (1993): Acute leukemiasof different lineages have similar MLL gene fusions encoding related chimeric proteins resulting from chromosomaltranslocation.Proc Natl Acad Sci USA 90:8538-8542. CorralJ, Lavenir1, Impey H, WarrenAJ, ForsterA, LarsonTA, Bell S, McKenzie ANJ, King G, RabbittsTH ( 1996): An MII-AF9 fusion gene madeby homologousrecombinationcauses acute leukemiain chimericmice: a method to createfusion oncogenes. Cell 85:853-861. CortesJE, KantarjianH, O’BrienS, KeatingM, PierceS, FreireichEJ, EstayE (1995): Clinicaland prognostic significanceof trisomy 21 in adult patientswith acute myelogenous leukemia and myelodysplasticsyndromes.Leukemia 9: 1 15-1 17. Cox MC, PanettaP, Lo-COCO F, Del PoetaG, VendittiA, MaurilloL, Del PrincipeMI, MaurielloA, AnemonaL. BrunoA, MazzoneC. PalomboP, AmadoriS (2004):Chromosomalaberrationof the 1lq23 locus in acute leukemiaand frequencyof M U gene translocation:resultsin 378 adult patients.Am J Clin Pathol 122:298-306. CraneMM, StromSS, Halabi S, BermanEL, FuegerJJ, Spitz MR, KeatingMJ (1996): Correlation between selected environmentalexposuresand karyotypein acute myelocytic leukemia.Cancer Epidemiol Biomarkers Prev 5:639-644. CuneoA, Van OrshovenA. MichauxJL, BoogaertsM, Louwagie A, Doyen Ch Dal Cin P, Fagioli F, Castoldi G, Van Den Berghe H (1990): Morphologic,immunologicand cytogenetic studies in erythroleukaemia:evidence for multilineage involvement and identificationof two distinct cytogenetic-clinicopathologicaltypes. Br J Haematol75:346-354. CuneoA, MichauxJ-L,FerrantA, Van Hove L, Bosly A, StulM, Dal CinP, VandenbergheE, Cassiman J-J. Negrini M, Piva N, CastoldiG,van den Berghe H (1992): Correlationof cytogeneticpatterns and clinicobiological featuresin adult acute myeloid leukemia expressing lymphoid markers. Blood 79:72&727. CuneoA, FerrantA, MichauxJL, BoogaertsM, DemuynckH, Van OrshovenA, CrielA, Stul M, Dal CinP, HernandezJ,ChatelainB, Doyen C, LouwagieA, CastoldiG, CassimanJ-J,Van Den Berghe H ( 1995): Cytogenetic profile of minimallydifferentiated(FAB MO) acute myeloid leukemia: correlationwith clinicobiologic findings.Blood 853688-3694. Cuneo A, FerrantA, Michaux J-L, Demuynck H, Boogaerts M, Louwagie A, Doyen C, Stul M, Cassiman J-J, Dal Cin P, Castoldi G, Van den Berghe H (1996): Philadelphiachromosomepositive acute myeloid leukemia:cytoimmunologicand cytogenetic features.Haematologica 8 1:423-427. CuthbertG, ThompsonK, McCulloughS, WatmoreA, DickinsonH,TelfordN, MugneretF, Harrison C, Griffiths M,Bown N (2000): MLL amplificationin acuteleukaemia:a United KingdomCancer CytogeneticsGroup(UKCCG)study.Leukemia 14:1885-1 891. DaenenS, VellengaE, van DobbenburghOA, Halie MR ( 1986):Retinoicacidas antileukemictherapy in a patientwith acute promyelocyticleukemia and Aspergillus pneumonia.Blood 67559-56 1. Dang CV, Stein PH, Gress DR, DallabettaGA, Bender WL (1985): A case of agnogenic myeloid metaplasiaevolvinginto acutemyelogenousleukemiaassociatedwith the developmentof trisomy I I in bone marrowcells. Am J Hemuto/ 19285-288. Daniel M-T,BernheimA, FIandrinG, BergerR (1985): Leucemieaigue myeloblastique(M2) avec atteintede la lignbe basophileet anomaliesdu brascourtdu chromosome12(12p). CR Acad Sci 301 :299-30 I.

108

ACUTE MYELOID LEUKEMIA

DastugueN. Payen C, Lafage-PochitaloffM, BernardP, Leroux D, Huguet-Riga1F, StoppaA-M, MaritG, MolinaL, MichalletM,MaraninchiD, AttalM, ReiffersJ ( 1 995): Prognosticsignificance of karyotypein de novo adult acute myeloid leukemia.Leukemia9:1491-1498. DastugueN, Lafage-PochitaloffM, Pagbs MP, RadfordI, BastardC, TalmantP, MozziconacciMJ. Leonard C, Bilhou-NaberaC, Cabrol C, Capodano A-M, Comillet-LefebvreP, Lessard M, Mugneret F, Per01 C, Taviaux S, Fenneteaux0, Duchayne E, Berger R (2002): Cytogenetic profileof childhoodandadultmegakaryoblasticleukemia(M7): a studyof the GmupeFrancaisde CytogenetiqueHematologique(GFCH).Blood 1 W 618-626. Davey DD, Patil SR, EchternachtH, Fatemi C, Dick FR (1989): 8:21 translocationin acute nonlymphocytic leukemia. Occurrence in M I and M2 FAB subtypes. Am J Clin Pathol 92: 172-176. Davey FR, AbrahamN Jr,BrunettoVL, MacCallumJM, Nelson DA, Ball ED, GriffinJD, BaerMR, Wurster-HillD, MayerRJ, SchifferCA, Bloomfield CD (1995): Morphologiccharacteristicsof erythroleukemia(acutemyeloid leukemia;FAB-M6): a CALGBstudy.Am JHematol49:29-38. Davico L, SacerdoteC, Ciccone G, Pegoran,L, KerimS, PonzioG , Vineis P (1998): Chromosome8, occupationalexposures,smoking,andacutenonlymphocyticleukemias:a population-basedstudy. CancerEpidemiolBiomarkersPrev7:I 123-1 125. De BottonS, ChevretS, Sanz M, DombretH, ThomasX, GuerciA, Fey M,RayonC, HuguetF, SottoJJ, GardinC, Cony MakhoulP, TravadeP, SolaryE, FegueuxN, BordessouleD, San Miguel J, Link H, Desablens B, StamatoullasA, Deconinck E, Geiser K, Hess U. Maloisel F, Castaigne S. PreudhommeC, ChomienneC, Degos L, FenauxP (2000):Additionalchromosomalabnormalities in patientswith acutepromyelocyticleukaemia(APL)do notconferpoorprognosis:resultsof APL 93 hid.Br J Huematol 1 1 l:801-806. de la ChapelleA, LahtinenR (1983): ChromosomeI6 and bone-marroweosinophilia.N Engl JMed 309: 1394. DelaunayJ, Vey N, LeblancT, Fenaux P, Rigal-HuguetF, Witz F, LamyT, AuvrignonA, Blaise D, Pigneux A, MugneretF, BastardC, DastugueN, Van den AkkerJ. FiereD, ReiffersJ, Castaigne S, Leverger G , Harousseau J-L, Dombret H (2003): Prognosis of inv(16)/t(l6;16) acute myeloid leukemia (AML): a survey of I10 cases from the French AML Intergroup.Blood 102:462469. DerreJ,CherifD, Le ConiatM, JulierC, BergerR ( 1990):In situhybridizationascertainsthepresenceof a translocationt(6;ll) in an acute monocyticleukemia.Genes ChromosomesCancer2:341-344. de The H,ChomienneC, LanotteM,Degos L, Dejean A ( 1990):The t( 15; 17) translocationof acute promyelocyticleukaemiafuses the retinoic acid receptorCL gene to a novel transcribedlocus. Nature347:558-561. DetourmigniesL, CastaigneS, StoppaAM, HarousseauJL,SadounA, JanvierM,DemoryJL,SanzM, Berger R, Bauters F, Chomienne C, Fenaux P ( 1 992): Therapy-relatedacute promyelocytic leukemia:a reporton 16 cases. J Clin Oncol 10:1430-1435. acute nonlymphocytic DeVore R, WhitlockJ, HainsworthJD. JohnsonDH ( 1 989): Therapy-related leukemia with monocytic features and rearrangementof chromosome 1 Iq. Ann Intern Med 110740-742. DewaldGW, Momson-DeLapSJ, SchuchardK A , SpurbeckJL, PierreRV (1983): A possiblespecific chromosomemarkerfor monocytic leukemia: three more patients with t(9;l l)(p22;q24) and anotherwith t(l1;17)(q24;q21).each with acutemonoblasticleukemia.CuncerGenetCytogenet 8:203-212. Dicker F, HaferlachC, Kern W, HaferlachT, SchnittgerS (2007): Trisomy I3 is stronglyassociated with AMLI/RUNXI mutationsand increasedFLT3 expressionin acutemyeloid leukemia.Blood 1 1 0 1308-1316. Djabali M, Selleri L, ParryP, Bower M, Young BD, Evans GA (1992): A trithorax-likegene is interruptedby chromosomeI lq23 translocationsin acute leukaemias.Nut Genet 2: 1 13-1 18.

REFERENCES

109

DohnerH, ArthurDC, Ball ED, Sob01RE, Davey FR,LawrenceD, GordonL, PatilSR, SuranaRB, TestaJR, Verma RS, SchifferCA, Wurster-HillDH, Bloomfield CD (1990): Trisomy 13: a new recurringchromosomeabnormalityin acute leukemia.Blood 76: 1614-162 I. DijhnerK, BrownJ, HehmannU, HetzelC, StewartJ, LowtherG, SchollC, FrohlingS, CuneoA, Tsui of a critical LC, LichterP, SchererSW, DahnerH (1998): Molecularcytogeneticcharacterization region in bands 7q35-q36 commonly deleted in malignant myeloid disorders. Blood 92403 14035. DreylingMH,Martinez-Climent JA,ZhengM, MaoJ,Rowley JD, BohlanderSK (1996):Thet( 10;11) (p13;q14) in the U937 cell line results in the fusion of the AFlO gene and CALM, encoding a new member of the AP-3 clathrin assembly protein family. Proc Natl Acad Sci USA 93:48044809. DreylingMH, SchraderK, FonatschC, SchlegelbergerB, HaaseD, ScochC, LudwigW-D, Lijffler H, BiichnerT, WormannB, HiddemannW, BohlanderSK (1998):MLL and CALMare fused to AFlO in morphologicallydistinctsubsetsof acuteleukemiawith translocationt(l0;1 I): both rearrangements are associated with a poor prognosis.Blood 91 :4662-4667. DusenberyKE, Howells WB, ArthurDC,Alonzo T, Lee JW, KobrinskyN, BamardDR, Wells RJ, Buckley JD, Lange BJ, Woods WG (2003): Extramedullaryleukemia in childrenwith newly diagnosedacutemyeloidleukemia:a report fromthe Children’sCancerGroup.JfediatrHematol Oncol25:760-768. EbertBL, PretzJ, Bosco J, ChangCY, TamayoP, Galili N, RazaA, RootDE, AttarE, Ellis SR, Golub TR (2008): ldentificationof RPSl4 as a 5q- syndromegene by RNA interferencescreen.Nature 451 :335-339. ElagibKE, GoldfarbAN (2007): Oncogenic pathwaysof AMLl-ETO in acute myeloid leukemia: multifacetedmanipulationof marrowmaturation.CancerLett 25 1 :179-186. ElliottMA, LetendreL, HansonCA, Tefferi A, Dewald GW (2002): The prognosticsignificanceof trisomy 8 in patientswith acute myeloid leukemia.Leuk Lymphoma43583-586. El-Rifai W, Elonen E, LarramendyM, RuutuT, KnuutilaS ( 1997): Chromosomalbreakpointsand changes in DNA copy numberin refractoryacute myeloid leukemia.Leukemia 11:958-963. EricksonP, Gao J, ChangK-S,Look T, WhisenantE, RaimondiS,LasherR, TrujilloJ, Rowley JD, Drabkin H (1992): Identificationof breakpointsin t(8;21) acute rnyelogenous leukemia and isolationof a fusiontranscript,AMLUETO, with similarityto Drosophilasegmentationgene, mnt. Blood 80: 1825-1 83 1. EriksonJ, GriffinCA, Ar-RushdiA, Valtien M, Hoxie J, FinanJ, EmanuelBS, RoveraG, Nowell PC, (Ph +) Croce CM (1986): Heterogeneityof chromosome22 breakpointin Philadelphia-positive acute lymphocyticleukemia.Proc Natl Acad Sci USA 83: 1807-18 I I. Estey E, TrujilloJM, CorkA, O’BrienS, BeranM, KantarjianH, KeatingM, FreireichELI, Stass S (1992): AML-associatedcytogenetic abnormalities(inv(l6), del(16). t(8;21)) in patientswith myelodysplasticsyndromes.HematolPathol6:4348. Falini B, BigernaB, PucciariniA, Tiacci E, MecucciC, Moms SW,Bolli N, RosatiR, HanissianS, Ma Z, Sun Y, ColomboE, ArberDA, PaciniR, La Stami R, VerducciGallettiB, Liso A, MartelliMP, F. Martelli MF (2006): Aberrantsubcellularexpression of Diverio D, Pelicci PG, Lo COCO nucleophosminand NPM-MLF1 fusion protein in acute rnyeloidleukaemiacarryingt(3;5): a comparisonwith NPMc AML. Leukemia20:368-37 1. Falini B, Nicoletti I, Bolli N, MartelliMP, Liso A, Gorello P, Mandelli F, Mecucci C, MartelliMF (2007): Translocationsand mutationsinvolvingthe nucleophosmin( N P M I ) gene in lymphomas and leukemias.Haematologica9 2 5 19-532. FaragSS,ArcherKJ, Mr6zekK, VardimanJW,CarrollAJ, PettenatiMJ,MooreJO, Kolitz JE,Mayer RJ, StoneRM, LarsonRA, BloomfieldCD (2002): Isolatedtrisomyof chromosomes8, I 1,13 and 21 is an adverseprognosticfactor in adultswith de novo acute myeloid leukemia:resultsfrom Oncol21:1041-1051. Cancerand LeukemiaCroupB 8461. Int .I

+

110

ACUTE MYELOID LEUKEMIA

Felix CA, Hosler MR, Winick NJ, MastersonM, Wilson AE, Lange BJ (1995): ALL-I gene rearrangements in DNA topoisomeraseTI inhibitor-relatedleukemiain children.Blood 63250-3256. Felix CA, Kolaris CP, Osheroff N (2006): Topoisomerase [I and the etiology of chromosomal translocations.DNA Repair 5: 1093-1 108. Fenaux P, PreudhommeC, Lai JL, Morel P, Beuscart R, Bauters F (1989): Cytogenetics and their prognosticvaluein denovo acutemyeloidleukaemia:a reporton 283 cases. Br JHaemato173:61-67. Fenaux P, Le Deley MC, CastaigneS, ArchimbaudE, ChomienneC, Link H, Guerci A, Duarte M, Daniel MT, Bowen D, HuebnerG, BautersF, FegueuxN, Fey M, SanzM,LowenbergB, Maloisel F, AuzanneauG, Sadoun A, GardinC, Bastion Y,GanserA, Jacky E, Dombret H, ChastangC, Degos L ( 1993): Effect of all transretinoicacid in newly diagnosed acute promyelocyticleukemia. Results of a multicenterrandomizedtrial. Blood 82:3241-3249. FerrantA, LabopinM, Frassoni F, PrenticeHG, Cahn JY, Blaise D, Reiffers J, Visani G . Sanz MA, Boogaerts MA, Lowenberg B, Gorin NC (1997): Karyotype in acute myeloblastic leukemia: prognostic significance for bone marrowtransplantationin first remission: a Europeangroupfor blood and marrowtransplantationstudy. Blood 90:293 1-2938. FerraraF, Scognamiglio M,Di Noto R, SchiavoneEM,Poggi V, Fiorillo A, LibertiniR, VicariL, Del Vecchio L, Sebastio L ( 1996): Interstitial9q deletion is associated with CD7 + acute leukemiaof myeloid and T lymphoid lineage. Leukemia LO: 1990-1992. FerraraF, Di Noto R, Annunziata M. Copia C, Lo Pardo C, Boccuni P, Sebastio L, Del Vecchio L (1998): lmmunophenotypicanalysis enables the correct prediction of t(8:21) in acute myeloid leukaemia.Br J Haematol 102:444-448. FerrariS, GrandeA, ZucchiniP, ManfrediniR, TagliaficoE, Rossi E, TemperaniP, TorelliG, EmiliaG, Torelli U ( 1993): Overexpressionof C-kit in a leukemiccell populationcarryinga trisomy4 andits relationshipwith the proliferativecapacity. Leuk Lymphoma9:495-50 I . Fichelson S, Dreyfus F, Berger R, Melle J. Bastard C, Miclea JM, Gisselbrecht S (1992): Evi-1 expression in leukemic patients with rearrangementsof the 3q25-q28 chromosome region. Leukemia 6193-99. FioretosT, StrombeckB, SandbergT,JohanssonB, BillstromR, Borg A, Nilsson P-G,Van Den Berghe H, HagemeijerA, Mitelman F, Hoglund M ( 1999): lsochromosorne 17q in blast crisis of chronic myeloid leukemiaand in otherhematologicmalignanciesis the resultof clusteredbreakpointsin 17pI1 and is not associated with coding TP.53 mutations. Blood 94:225-232. FitzgibbonJ, SmithL-L, RaghavanM, SmithML,DebernardiS, SkoulakisS, Lillington D, ListerTA, Young BD (2005): Association between acquired uniparentaldisomy and homozygous gene mutation in acute rnyeloid leukemias. Cancer Res 659152-91 S4. FIWCL(FourthInternationalWorkshopon Chromosomesin Leukemia, 1982) (1 984a): Abnormalities of chromosome 22. Cancer Genet Cyrogenet 1 I :3 16-3 18. FIWCL (Fourth InternationalWorkshopon Chromosomes in Leukemia, 1982) (1 984b): Clinical significance of chromosomalabnormalitiesin acute nonlymphoblasticleukaemia.Cancer Genet Cytogenel I 1:332-350. FlynnPJ,MillerWJ,WeisdorfDJ, ArthurDC, BrunningR, BrandaRF(1983):Retinoicacid treatment of acutepromyelocytic leukemia: in vitro and in vivo observations.Blood 6 2 121 1-1217. FonatschC, GudatH, LengfelderE, WandtH, Silling-EngelhardtG, Ludwig W-D, Thiel E, FreundM, Bodenstein H, SchwiederG, GruneisenA, Aul C. SchnittgerS, RiederH, Haase D. Hild F ( 1994): Correlationof cytogenetic findings with clinical features in 18 patients with inv(3)(q21q26) or t(3;3)(q21;q26). Leukemia 8: I3 18-1326. FontanaJA, Rogers JS 2nd, DurhamJP (1986): The role of 13 cis-retinoic acid in the remission induction of a patient with acute promyelocyticleukemia. Cancer 57:209-217. ForestierE, Heim S, Blennow E, BorgstromG, HolmgrenG. Heinonen K, JohannssonJ, KerndrupG, AndersenMK, LundinC. NordgrenA, Rosenquist R, Swolin B, JohanssonB (2003): Cytogenetic

REFERENCES

111

abnormalitiesin childhood acute myeloid leukaemia: a Nordic series comprising all children enrolled in the NOPHO-93-AML trial between 1993 and 2001. Br J Haematol 121566-577. ForestierE, Izraeli S, Beverloo B, Hass 0, Pession A, Michalova K, StarkB. HarrisonCJ, TeiglerSchlegel A. Johansson B (2008): Cytogenetic features of acute lymphoblastic and myeloid leukemias in pediatric patients with Down syndrome: an iBFM-SG study. Blood I 1 1: 1575-1583. Fomerod M, Boer J, van Baal S, JaeglBM, von Lindern M, Murti KG, Davis D, Bonten J, Buijs A, Grosveld G (1995): Relocation of the carboxyterminalpart of CAN from the nuclear envelope to the nucleus as a result of leukemia-specific chromosome rearrangements. Oncogene 10:1739-1 748. ForrestDL, Nevill TJ, HorsmanDE, BmkingtonDA, Fung HC, Toze CL, Conneally EA, Hogge DE, Sutherland HJ, Nantel SH, Shepherd JD, Barnett MJ (1998): Bone marrow transplantation for adults with acute leukaemia and llq23 chromosomal abnormalities. Br J Haematol 103:630-638. FrohlingS, Schlenk RF, KrauterJ, ThiedeC, EhningerG, Haase D, HarderL, KreitmeierS, Scholl C, CaligiuriMA, Bloomfield CD, DohnerH, WhnerK (2005): Acute myeloid leukemiawith deletion 9q within a noncomplex karyotypeis associated with CEBPA loss-of-function mutations.Genes Chromosomes Cancer 42:427432. FujinoT. Suzuki A, it0 Y, Ohyashiki K, HatanoY, MiuraI, NakamuraT (2002): Single-translocation anddouble-chimerictranscripts:detectionofNUP98-HOXA9in myeloid leukemiaswith HOXAl I or HOXA13 breaksof the chromosomaltranslocationt(7; 1l)(p15;p15). Blood 99: 1428-1433. GaleRP, HorowitzMM,WeinerRS, Ash RC,Atkinson K, BabuR, Dicke KA, Klein JP,LowenbergB, Reiffers J, Rimm AA, Rowlings PA, SandbergAA, Sobocinski KA, Veum-StoneJ, Bortin MM (1995): Impact of cytogenetic abnormalitieson outcome of bone marrow transplantsin acute myelogenous leukemia in first remission. Bone Marrow Transplant 16:203-208. Gale RE, Hills R, Pizzey AR, KottaridisPD, SwirskyD, Gilkes AF, Nugent E, Mills KI, Wheatley K, Solomon E, BurnettAK, Linch DC, GrimwadeD (2005): Relationshipbetween FLT3 mutation status,biologic characteristics,and responseto targetedtherapyin acute promyelocyticleukemia. Blood 106:3768-3776. GamerdingerU, Teigler-Schlegel A, Pils S, BruchJ,ViehmannS, KellerM, JauchA, HarbottJ (2003): Crypticchromosomalaberrationsleading to an AMLILETO rearrangementarefrequentlycaused by small insertions. Genes Chromosomes Cancer 36:26 1-272. GargonL. LiburaM, Delabesse E, Valensi F, Asnafi V, Berger C, Schmitt C, Leblanc T, Buzyn A, Macintyre E (2005): DEK-CAN molecular monitoring of myeloid malignancies could aid therapeuticstratification.Leukemia 19:1338-1 344. Geraedts JPM, den OttolanderGJ, Ploem JE, Muntinghe OG (1 980): An identical translocation between chromosome 1 and 7 in three patients with myelofibrosis and myeloid metaplasia.Br J Haematol44.569-575. GFCH (GroupeFraqaisde CytoghnbtiqueHCmatologique)( 1990): Acute myelogenous leukemia with an 8;21 translocation.A reporton 148 cases from the Groupe Franpisde CytogCnCtique Hkmatologique.Cancer Genet Cytogenet 44: 169-1 79. GhaddarHM, PlunkettW, KantarjianHM,PierceS, FreireichEJ,KeatingMJ,Estey EH(1994): Longterm results following treatmentof newly-diagnosed acute myelogenous leukemiawith continuous-infusion high-dose cytosine arabinoside.Leukemia 8:1269-1 274. GibbonsB, Czepulkowski B, TuckerJ, SimpsonE, Amess JAL, Young BD, ListerTA (1987): Subtle abnormalitiesin the short arm of chromosome I 1 in acute myeloid leukemia. Cancer Genet Cytogencl 28287-297. Gibbons B, Lillington DM, Monard S, Young BD, Cheung KL, Lister TA, Keamey L (1994): Fluorescence in situ hybridisationstudies to characterisecomplete and partial monosomy 7 in myeloid disorders. Genes Chromosomes Cancer 10:244-249.

112

ACUTE MYELOID LEUKEMIA

Giles RH,Dauwerse JG, Higgins C, Petrij F, Wessels JW, Beverstock GC, Dohner H, JotterandBellomo M, FalkenburgJHF,Slater RM, van Ommen G-JB Hagemeijer A, van der Reijden BA, Breuning MH (1997): Detection of CBP rearrangementsin acute myelogenous leukemia with t(8;16). Leukemia 11:2087-2096. Glass JP, Van Tassel P, Keating MJ, Cork A, TrujilloJ, Holmes R (1987): Centralnervous system complicationsof a newly recognized subtypeof leukemia:AMML with a pericentricinversionof chromosome 16. Neurology 37:639-644. Goddard AD, Borrow J, Freemont PS, Solomon E (1991): Characterizationof a zinc finger gene disruptedby the t( 15;17) in acute promyelocytic leukemia. Science 254:1 37 1- 1374. GolombHM, Rowley J, VardimanJ, BaronJ, LockerG, KrasnowS ( I 976): Partialdeletionof long arm of chromosome 17. A specific abnormalityin acute promyelocytic leukemia?Arch fntern Med 136825-828. Golomb HM, VardimanJW,Rowley JD, Testa JR, Mintz U (1978): Correlationof clinical 6ndings withquinacrine-bandedchromosomesin 90 adultswith acutenonlymphocyticleukemia.An eightyear study (1970-1977). N EnglJ Med 299:613-619. GolubTR, BarkerGF, Lovett M, Gilliland DG ( 1994):Fusion of PDGFreceptorp to a novel ets-like gene, tel, in chronic myelomonocytic leukemia with t(5;12) chromosomal translocation.Cell 77~307-316. GorlettaTA, GaspariniP, D’Elios MM, TrubiaM, Pelicci PG,Di Fiore PP (2005): Frequentloss of heterozygosity without loss of genetic material in acute myeloid leukemia with a normal karyotype.Genes ChromosomesCancer44:334-337. Govberg IJ, Wolf JL, CotterPD (2000): Trisomy 4 and double minutes in acute myeloid leukemia: furtherevidence that double minutes can occur as the primarycytogenetic abnormality.Cancer Genet Cytogenet 121:212-215. Grigg AP,Gascoyne RD, Phillips GL. HorsmanDE ( 1 993): Clinical, haematologicaland cytogenetic features in 24 patients with structuralrearrangementsof the Q arm of chromosome 3. Br J Haematol83:158-165. GrimwadeD, GormanP, DuprezE, Howe K, LangabeerS,Oliver F, WalkerH, Culligan D, WatersJ, PomfretM,GoldstoneA, BurnettA, FreemontP, SheerD, Solomon E (1997): Characterizationof cryptic rearrangementsand variant translocations in acute promyelocytic leukemia. Blood 90:487&4885. GrimwadeD, WalkerH, Oliver F, Wheatley K, Hamson C, HarrisonG, Rees J, Hann I, Stevens R, Bumett A, GoldstoneA (1998): The importanceof diagnosticcytogenetics on outcome in AML: analysis of I,612 patientsentered into the MRC AML 10 trial. Blood 92:2322-2333. GrimwadeD, Biondi A, Mozziconacci M-J, HagemeijerA, BergerR, Neat M,Howe K, DastugueN, JansenJ, Radford-WeissI, Lo Coco F, Lessard M, HernandezJ-M, Delabesse E, Head D, Liso V, SaintyD, FlandrinG, Solomon E, Birg F, Lafage-PochitaloffM (2000): Characterizationof acute promyelocytic leukemiacases lacking the classic t( 15; 17): resultsof the EuropeanWorkingParty. Blood 96:1297-1 230. Grois N, Nowotny H, Ty1 E, Krieger 0, Kier P, Haas OA (1989): Is trisomy 22 in acute myeloid leukemiaa primaryabnormalityor only a secondarychange associated with inversion I6? Cancer Genet Cytogenet 43: 119- 129. Guglielmi C, Martelli MP, Diverio D, Fenu S, Vegna ML, Cantu-RajnoldiA, Biondi A, Cocito MG, Del Vecchio L, Tabilio A, Avvisati G, Basso G, Lo Coco F ( 1998):Immunophenotypeof adultand childhood acute promyelocytic leukaemia: correlation with morphology, type of PML gene breakpoint and clinical outcome. A cooperative Italian study on 196 cases. Br J Haernatol 102:1035-1 041. Guidez F, Huang W, Tong J-H, Dubois C, BalitrandN, WaxmanS, MichauxJL, MartiatP, Degos L, Chen Z, ChomienneC (1 994): Poor responseto all-transretinoic acid therapyin a t(1 1 ;17) PLZF/ RARa patient. Leukemia 8:312-3 17.

REFERENCES

113

GuptaV, MindenMD, Yi Q-L, BrandweinJ, ChunK (2003): Prognosticsignificanceof trisomy4 as the sole cytogenetic abnormalityin acute myeloid leukemia. LRuk Res 27:983-991. HaferlachT,BennettJM,LofflerH, GassmannW, AndersenJW, TuzunerN,CassllethPA, FonatschC, Schoch C, SchlegelbergerB, Becher R, Thiel E, Ludwig W-D, SauerlandMC, Heinecke A, BiichnerT (1996a): Acute myeloid leukemiawith translocation(8;21). Cytomorphology,dysplasia and prognosticfactorsin 41 cases. k u k Lymphoma 23:227-234. HaferlachT, WinkemannM,L6ffler H, Schoch R, GassmannW, FonatschC, SchochC, PoetschM, Weber-MatthiesenK. SchlegelbergerB (1996b): The abnormaleosinophils are part of the leukemic cell populationin acute myelomonocytic leukemiawith abnormaleosinophils(AML M4Eo) and carrythe pericentricinversion 16: a combinationof May-Griinwald-Giemsastaining and fluorescencein situ hybridization.Blood 87:2459-2463. HaferlachT, Schoch C, SchnittgerS, Kern W, Loffler H, HiddemannW (2002): Distinct genetic patternscan be identifiedin acute monoblasticand acutemonocyticleukaemia(FAB AML M5a and M5b): a study of 124 patients.Br J Huemutol I 1 8:426-43 1. HaferlachT, KernW, Schoch C, SchnittgerS, SauerlandMC, HeineckeA, BuchnerT, HiddemannW (2004): A new prognosticscoreforpatientswith acutemyeloid leukemiabasedon cytogeneticsand earlyblastclearancein trialsoftheGermanAMLCooperativeGroup.Huematologica89:408-418. HagemeijerA, HWen K, Abels J (1981): Cytogeneticfollow-up of patientswith nonlymphocytic leukemia. 11. Acute nonlymphocyticleukemia. Cancer Genet Cytogenet 3:109-124. HagemeijerA, HahlenK, Sizoo W, Abels J (1982): Translocation(9;1 l)(p21:q23) in threecases of acute monoblasticleukemia.Cancer Gene1 Cytogenet 595-105. Hanslip J1, SwansburyGJ, PinkertonR, Catovsb.D (1 992): The translocationt(8;16)(pl1;pl3) defines an AML subtypewith distinctcytologyandclinicalfeatures.LeukLymphoma 6:479-486. HaradaH, Asou H, KyoT, AsaokuH, IwatoK, Dohy H, OdaK, HaradaY, Kita K, KamadaN ( 1995):A specific chromosome abnormalityof t(4;12)(q11-12;p13) in CD7 acute leukaemia. Br J Haemutol90850-854. Harbott J, Mancini M, Verellen-Dumoulin C, Moorman AV, Secker-WalkerLM (1998): Hematologicalmalignancieswith a deletionof I 1q23: cytogeneticand clinicalaspects.Leukemia 1 2~823-827. HarrisonCJ, Cuneo A. ClarkR, Johansson B, Lafage-PochitaloffM, Mugneret F, Moorman AV, Secker-WalkerLM (1998): Ten novel 1 lq23 chromosomalpartnersites. Leukemitr 12:811-822. HarrisonCJ,Radford-WeissI, Ross F, Rack K, le GuyaderG,VekemansM, MacintyreE (1999): Fluorescencein situ hybridizationanalysis of masked (8;2 l)(q22;q22) translocations.Cancer Genet Cylogenet 1 12:15-20. Hasle H, Alonzo TA, AuvrignonA, BeharC, ChangM, CreutzigU. FischerA, ForestierE, FYMA, Haas OA. HarbottJ, HarrisonCJ, Heerema NA, van den Heuvel-EibrinkMM, Kaspers GJL, Y.RazzoukB, ReinhardtD, Savva NN, Locatelli F, Noellke P,PolychronopoulouS, Ravindranath StarkB, Suciu S, TsukimotoI, WebbDK, WojcikD, WoodsWG, ZimmermannM,NiemeyerCM, RaimondiSC (2007):Monosomy7 anddeletion7q in childrenandadolescentswith acutemyeloid leukemia: an internationalretrospectivestudy. Blood I09:4641-4647. HatanoY, MiuraI, NakamuraT,YamazakiY, TakahashiN, MiuraAB (1999): Molecularheterogeneity of the NUP98JHOXA9 fusion transcriptin myelodysplasticsyndromesassociated with t(7;l l)(p15;p15). Br J Huemutol 107:-. Hayashi Y, Sakurai M. Kaneko Y, Abe T, Mori T, Nakazawa S (1985): I 1;19 translocationin a congenital leukemia with two cell populationsof lymphoblastsand monoblasts. k u k Res 9: 1467-1473. He L-Z, Guidez F, Tribioli C, Peruzzi D, RuthardtM, Zelent A, Pandolfi PP (1998): Distinct interactionsof PML-RARaandPLZF-RARawith co-repressorsdeterminedifferentialresponses to RA in APL. Nut Genet 18:126135.

+

114

ACUTE MYELOID LEUKEMIA

Heim S , Avanzi G-C, BillstromR, KristofferssonU, MandahlN, Bekassy AN, GarwiczS, WiebeT, PegoraroL, FaldaM, Resegotti L, MitelmanF (1987a): A new specific chromosomalrearrangement, t(8;16)(pl l;p13), in acute monocytic leukaemia.Br J Haematol66:323-326. Heim S , Bkkassy AN, Garwicz S , HeldrupJ, Wiebe T, KristofferssonU, MandahlN, Mitelman F ( L987b): New structuralchromosomal rearrangementsin congenital leukemia. Leukemia 1:16-23. Heim S , Egelund ChristensenB, FioretosT, Sorensen A-G, Tinggaad PedersenN ( 1992): Acute myelomonocyticleukemiawith inv(16)(pl3q22)complicatingPhiladelphiachromosomepositive chronicmyeloid leukemia.CancerGenet Cytogenet59:35-38. HernandezJM. MartinG, GutidrrezNC, CerveraJ, FerroMT, CalasanzMJ, Martinez-ClimentJA, Luno E, TormoM, Rayon C, Diaz-MediavillaJ, Gonzdez M, Gonzdez-San Miguel JD, PkrezEquizaK, RivasC, EstevcJ, Alvhez M del C, OdriozolaJ,RiberaJM,SanzMA (200 I ): Additional cytogenetic changes do not influence the outcome of patients with newly diagnosed acute promyelocyticleukemiatreatedwith an ATRA plus anthracyclinbased protocol. A reportof the SpanishgroupPethema.Haematologica86:807-8 13. HiornsLR, Min T, SwansburyGJ, Zelent A, Dyer MJS, CatovskyD (1994): lnterstitialinsertionof retinoicacid receptor-agene in acutepromyelocyticleukemiawith normalchromosomes15 and 17. Blood 83:2946-2951. Hogge DE, Misawa S , ParsaNZ, Pollak A, TestaJR (1984a): Abnormalitiesof chromosome16 in associationwith acutemyelomonocyticleukemiaand dysplasticbone marroweosinophils.J Clin Oncol2:550-557. Hogge DE, Misawa S , Schiffer CA. Testa JR (1984b): Promyelocytic blast crisis in chronic granulocyticleukemiawith 15;17 translocation.Leuk Res 8:1019-1023. Hoglund M, Johansson B, Pedersen-BjergaardJ, Marynen P, Mitelman F (1996): Molecular characterization of 12p abnormalitiesin hematologicmalignancies:deletionof KZPl, rearrangement of TEL, and amplificationof CCND2. Blood 87:324-330. Holmes R, Keating MJ, Cork A, Broach Y. TrujilloJ, Dalton WT Jr, McCredieKB, FreireichEJ (1 985a): A uniquepatternof centralnervoussystem leukemiain acutemyelomonocyticleukemia associated with inv(16)(p13q22).Blood 65: 1071-1078. Holmes R1, Keating MJ, Cork A, TrujilloJM, McCredieKB, FreireichEJ (1985b): Loss of the Y chromosomein acute myelogenousleukemia:a report of 13 patients. CancerGenet Cytogenet 17~269-278. Hoyle C, ShemngtonPD, Hayhoe FGJ (1987): Cytologicalfeaturesof 9q- deletions in AML. Br J Haematol66:277-278. Hoyle CF, de Bastos M, Wheatley K, ShemngtonPD, FischerPJ, Rees JKH,Gray R, Hayhoe FGJ ( 1989a):AML associatedwith previouscytotoxic therapy,MDS or myeloproliferative disorders: resultsfrom the MRC’s9th AML trial. Br J Haematol72:45-53. Hoyle CF,SherringtonPD, FischerP, Hayhoe FGJ (1989b): Basophilsin acutemyeloid leukaemia. J Clin Pathol42:785-792. Hru%k0, Ponvit-MacDonaldA (2002): Antigen expression patternsreflectinggenotype of acute leukemias.Leukemia I 6 1233-1 258. Hsiao H-H, SashidaG, Ito Y,KodamaA, FukutakeK, OhyashikiJH,OhyashikiK (2006):Additional cytogeneticchanges and previousgenotoxic exposurepredictunfavorableprognosis in myelodysplasticsyndromesand acute myeloid leukemiawith der(1;7)(qlO;p10). CancerGenet Cytogenet 165:161-166. Hsu LYF, GreenbergML, Kohan S , WittmanR (1979): Trisomy I3 in bone marrowcells in acute myelocytic leukemiaand myelofibrosis.Clin Genet I5:327-33 I . HuangM-E,Ye Y-C, ChenS-R, ChaiJ-R, LuJ-X, ZhoaL, Gu L-J,WangZ Y ( I 988): Use of all-trans retinoicacid in the treatmentof acute promyelocyticleukemia.Blood 72567-572.

REFERENCES

115

HuangS-Y, Tang3-L,LiangY-J, WangC-H,ChenY-C, TienH-F(1997): Clinical,haematologicaland molecular studies in patients with chromosometranslocationt(7;I I): a study of four Chinese patientsin Taiwan.Br J Huemaiol96682-687. HudsonMM, RaimondiSC, Behm FG, Pui C-H ( 199I): Childhoodacuteleukemiawith t( I I ;19)(q23; p13). Leukemia5:1064-1068. HuebnerK, Isobe M, Croce CM, Golde DW, Kaufman SE, Gasson JC (1985): The human gene encodingGM-CSFis at 5q2I -q32, the chromosomeregion deleted in the 5q- anomaly.Science 230: 1282-1285. HummelJL, Wells RA, Dub6 ID, LichtJD, Kamel-ReidS ( 1999): Deregulationof NPM andPLZFin a variantt(5: 17) case of acute promyelocyticleukemia. Oncogene 18:633-641. HungerSP,TkachukDC, Amylon MD, Link MP, CarrollAJ, WelbornJL, WillmanCL, Cleary ML (1993): HRX involvementin de novo and secondaryleukemiaswith diversechromosomeI lq23 abnormalities.Blood 8 I :3197-3203. HurdDD, VukelichM, ArthurDC, LindquistLL, McKennaRW, PetersonBA, BloomfieldCD (1982): 15;17 translocationin acute promyelocyticleukemia.CancerGenet Cytogenel6:331-337. HuretJL,BrizardA, SlaterR, Charrin C, BertheasMF,GuilhotF, H a e n K,Kroes W,van LeeuwenE, SchootEVD, BeishuizenA, TanzerJ, HagemeijerA (1993): Cytogeneticheterogeneityin t( 1I ;19) acuteleukemia:clinical,hematologicalandcytogeneticanalysesof 48 patients- updatedpublished cases and 16 new observations.Leukemia7:152-160. HurwitzCA, RaimondiSC, Head D, KranceR, MirroJ Jr, KalwinskyDK, Ayers GD, Behm FG ( 1992): Distinctiveimmunophenotypic featuresof t(8;2l)(q22;q22)acute myeloblasticleukemia in children.Blood 80:3 182-3 188. IchikawaH, ShimizuK, HayashiY, OhkiM ( 1994):An RNA-bindingproteingene, TWFUS, is fused to ERG in human myeloid leukemia with t( 16;21) chromosomal translocation.Cancer Res 54:2865-2868. IidaS, SetoM, YamamotoK, KomatsuH, TojoA, AsanoS, KamadaN, AriyoshiY, TakahashiT, Ueda R (I 993): M U T 3 gene on 9p22 involved in t(9;1 1) leukemiaencodesa serine/prolinerich protein homologousto MLLTl on 19~13.Oncogene8:3085-3092. ImashukuS, Hibi S, SakoM, Lin YW, IkutaK, NakataY, MoriT, IizukaS, Horibe K, TsunematsuY (2000): Hemophagocytosisby leukemicblasts in 7 acute myeloid leukemiacases with t( 16;21) (PI 1422). Commonmorphologiccharacteristicsfor this typeof leukemia.Cancer88:1970-1 975. ltoh M, OkazakiT, TashimaM, SawadaH, UchiyamaT ( I 999): Acutemyeloidleukemiawith t(5;ll): two case reports.Leuk Res 23:677-680. Iwase S, FurukawaY, Horiguchi-YamadaJ, Nemoto T, TakaharaS, KawanoT, SekikawaT, It0 K, YamazakiY, KikuchiJ, Morishita K, YamadaH ( 1 998): A novel variantof acutemyelomonocytic leukemia carryingt(3;12)(q26;p13) with characteristicsof 3q2lq26 syndrome.Int J Hernatol 67~361-368. JaffN, ChelghoumY,ElhamriM, TigaudI, MichalletM, ThomasX (2007):Trisomy8 as sole anomaly or with otherclonal aberrationsin acute myeloid leukemia:impacton clinical presentationand outcome. Leuk Res 31:67-73. Jaju RJ, Haas OA, Neat M, HarbottJ, Saha V, Boultwood J, Brown JM, Pirc-DanoewinataH, KringsBW,MullerU, Moms SW, WainscoatJS,KeameyL (1999): A new recurrenttranslocation, t(5;I I)(q35;pl5.5), associated with del(5q) in childhood acute myeloid leukemia. Blood 94~773-780. JajuRJ, FidlerC, Haas OA, StricksonAJ, WatkinsF, Clark K, Cross NCP, Cheng J-F, Aplan PD, Keamey L, Boultwood J, WainscoatJS (2001): A novel gene, NSDI, is fused to NUP98 in the t(5;l I)(q35;p15.5) in de novo childhoodacute myeloid leukemia.Blood 98:1264-1267. JohanssonB, MertensF, Mitelman F (1991): Geographicheterogeneityof neoplasia-associated chromosomeaberrations.Genes ChromosomesCancer3: 1-7.

116

ACUTE MYELOID LEUKEMIA

Johansson B, Mertens F, Mitelman F (1994): Secondary chromosomal abnormalities in acute leukemias. Leukemia 8:953-962. JohanssonB. MertensF, Mitelman F (1996): Primaryvs. secondary neoplasia-associatedchromosomal abnormalities- balanccd rearrangementsvs. genomic imbalances? Genes Chromosomes Cancer 16:155-1 63. Johansson B, Moorman AV, Haas OA. WatmoreAE, Cheung KL, Swanton S, Secker-WalkerLM ( 1998a): Hematologic malignancies with t(4; I l)(q2 1;q23) - a cytogenetic, morphologic, immunophenotypic and clinical study of I83 cases. Leukemia 12:779-787. JohanssonB, MoormanAV, Secker-WalkerLM (1 998b): Derivativechromosomesof 1 Iq23-translocations in hematologic malignancies. Leukemia 12328-833. JohanssonB, Fioretos T, KullendorffC-M, Wiebe T, BLkassy AN, Garwicz S, ForestierE, Roos G, AkermanM, MitelmanF, BillstromR (2000): Granulocyticsarcomasin body cavities in childhood acute myeloid leukemias with 1 1q23lMLL rearrangements. Genes Chromosomes Cancer 27: 136-142. J o s h JM. Fernald AA, TennantTR, Davis EM, Kogan SC. Anastasi J, CrispinoJD, Le Beau MM (2007): Haploinsufficiencyof EGRI,a candidategene in the del(5q). leads to the developmentof myeloid disorders.Blood I 10:719-726. KakizukaA, MillerWH Jr,Umesono K, WarrellRP, FrankelSR, MurtyVVVS, DmitrovskyE, Evans RM (1 991): Chromosomaltranslocationt( 15;17) in human acute promyelocytic leukemiafuses RARa with a novel putative transcriptionfactor. PML. Cell 66:663-674. KalraR, Dale D, FrcedmanM, Bonilla MA, Weinblatt M, Ganser A, Bowman P, Abish S, Priest J, Oseas RS, Olson K, PaderangaD, ShannonK (1995): Monosomy 7 and activatingRAS mutations accompany malignant transformation in patients v, ith congenital neutropenia. Blood 8 6 4579-4586. Kalwinsky DK, Raimondi SC, Schell MJ, MirroJ Jr, SantanaVM, Behm F, Dahl GV, Williams D (1990): Prognostic importanceof cytogenetic subgroupsin de novo pediatricacute nonlymphocytic leukemia. J Clin Oncol8:75-83. KamanoH,KubotaY,OhnishiH,TaokaT,TanakaT,IrinoS(1988): t(11;19)(q23.3;p13.3)inanadult with acute myelogenous leukemia.Jpn J Clin Hematol29:1493-1498. KandaY,MitaniK, TanakaT, TanakaK, Ogawa S, Yazaki Y,HiraiH (1997): Subcellularlocalization of the MEN, MLWMEN and truncatedMLL proteins expressed in leukemic cells carryingthe t( I1;19)(q23;p13.1) translocation.lnt J Hematol66:189-195. Kaneko Y, SakuraiM (1977): 15/17 translocationin acute promyelocytic leukaemia.Lancet I :961. KanekoY, Rowley JD,MaurerHS, VariakojisD, MoohrJ W (1982): Chromosomepatterninchildhood acute nonlymphocyticleukemia (ANLL). Blood 60:389-399. KanekoY,ShikanoT, Maseki N, SakuraiM, SakuraiM, TakedaT, Hiyoshi Y,MimayaJ-1,FujimotoT (1988): Clinical characteristicsof infant acute leukemia with or without I lq23 translocations. Leukemia 2:672-676. KantarjianHM,TalpazM, DhingraK, Estey E, KeatingMJ, Ku S, TrujilloJ, Huh Y,StassS, Kurzrock R (1991): Significance of the P210 versus PI90 molecular abnormalitiesin adultswith Philadelphia chromosome-positiveacute leukemia. Blood 78:2411-2418. Kappes F, ScholtenI, RichterN, GrussC, WaldmannT (2004): Functionaldomainsof the ubiquitous chromatinprotein DEK. Mol CeN BioI24:6000-6010. Katz F, Malcolm S, GibbonsB, Tilly R, Lam G, RobertsonME, CzepulkowskiB, Chessells J (1988): Cellularand molecularstudieson infantnull acute lymphoblasticleukemia.Blood 7 I :1438- 1447. Keamey L (2006): Multiplex-FISH(M-FISH): technique,developmentsand applications.Cytogenet Genome Res I 1 4 189- 198. KearneyL, Bower M, GibbonsB, Das S, ChaplinT,Nacheva E, Chessells JM, Reeves B, Riley JH, Lister TA, Young BD (1992): Chromosome 1 lq23 translocationsin both infant and adult acute

REFERENCES

117

leukemias are detected by in situ hybridization with a yeast artificial chromosome. Blood 80: 1659-1665. KeatingMJ, Cork A, Broach Y, Smith T, WaltersRS, McCredieKB, TrujilloJ, FreireichEl (1987): Towarda clinically relevantcytogenetic classificationof acute myelogenous leukemia. Leuk Res I 1 : I 19-133. Kere J, Ruutu T, Davies KA, Roninson IB, Watkins PC, Winqvist R, de la Chapelle A (1989): Chromosome7 long armdeletionin myeloid disorders:a narrowbreakpointregionin 7q22 defined by molecular mapping. Blood 73:230-234. Khalidi HS, Medeiros LJ. Chang KL, Brynes RK, Slovak ML, ArberDA ( 1 998): The immunophenotype of adult acute myeloid leukemia. High frequency of lymphoid antigen expression and comparison of immunophenotype.French-American-British classification, and karyotypic abnormalities.Am J Clin Path01 109:211-220. Kita K, Nakase K, Miwa H, Masuya M, Nishii K, Morita N, TakakuraN, Otsuji A, ShirakawaS, Ueda T, Nasu K, Kyo T, Dohy H, Kamada N (1992): Phenotypical characteristicsof acute myelocytic leukemia associated with the t(8;21)(q22;q22) chromosomal abnormality:frequent expression of immature B-cell antigen CD19 together with stem cell antigen CD34. Blood 80:470-477. Kitabayashi I, Aikawa Y, Nguyen LA, Yokoyama A, Ohki M (2001): Activation of AMLImediated transcriptionby MOZ and inhibition by the MOZ-CBPfusion protein. EMBO J 20: 7 I 84-7 196. Kiyoi H, Naoe T, Yokota S, Nakao M, Minami S, KuriyamaK, TakeshitaA, Saito K, Hasegawa S, ShimodairaS, TamuraJ, ShimazakiC, Matsue K, KobayashiH, ArimaN, SuzukiR, MorishitaH, Saito H, Ueda R, OhnoR (1 997): Internaltandemduplicationof FLT3 associated with leukocytosis in acute promyelocyticleukemia. Leukemia 1 1: 1447-1 452. KobayashiH, EspinosaR 111, ThirmanMJ,FemaldAA, ShannonK, Diaz MO, Le Beau MM, Rowley JD (1993a): Do terminaldeletionsof 1 1 q23 exist? Identificationof undetectedtranslocationswith fluorescence in situ hybridization.Genes Chromosomes Cancer 7:204-208. KobayashiH, EspinosaR 111,ThirmanMJ, Gill HJ,Femald AA, Dim MO, Le Beau MM, Rowley JD ( 1993b): Heterogeneity of breakpointsof 1lq23 rearrangementsin hematologic malignancies identified with fluorescence in situ hybridization.Blood 82:547-55 I. KobayashiH,MontgomeryKT, BohlanderSK, AdraCN, Lim BL, KucherlapatiRS, Donis-KellerH, Holt MS, Le Beau MM, Rowley JD (1994): Fluorescence in situ hybridization mapping of translocations and deletions involving the short arm of human chromosome 12 in malignant hematologic diseases. Blood 84:3473-3482. Kobayashi H, Arai Y, Hosoda F, Maseki N, Hayashi Y, Eguchi H, 0% M, Kaneko Y (1997a): Inversionof chromosome I I, inv(1 1 )(p 15q22), as a recurringchromosomalaberrationassociated with de novo andsecondarymyeloid malignancies:identificationof a PI clone spanningthe 1lq22 breakpoint.Genes Chromosomes Cancer 19:1 5 S 1 5 5 . KobayashiH, Hosoda F, Maseki N, SakuraiM, lmashukuS, OhkiM, KanekoY (1997b): Hematologic malignancies with the t(lQ1 l)(p13;q21) have the same molecular event and a variety of morphologicor immunologic phenotypes. Genes Chromosomes Cancer 20:253-259. Kobzev YN, Martinez-ClimentJ, Lee S, Chen J, Rowley JD (2004): Analysis of translocationsthat involve the NUP98 gene in patients with 1 lp15 chromosomalrearrangements.Genes Chromosomes Cancer 4 1:339-352. Kojima K, Sakai I, Hasegawa A, Niiya H, Azuma T, Matsuo Y, Fujii N, Tanimoto M, Fujita S (2004): FLJ10849, a septin family gene, fuses M U in a novel leukemiacell line CNLBC I derived from chronic neutrophilic leukemia in transformation with t(4;l I )(q21;q23). Leukemia 18:998-1005. KokenMHM,Reid A, QuignonF,Chelbi-AlixMK, Davies JM,KabarowskiJHS,ZhuJ, Dong S, Chen S-J,ChenZ, TanCC, LichtJ. WaxmanS, De The H, ZelentA (1 997): Leukemia-associatedretinoic

118

ACUTE MYELOID LEUKEMIA

acid receptora fusion partners,PML and PLZF,heterodimerizeandcolocalize to nuclearbodies. Proc Natl Acud Sci USA 94:10255-10260. KokenMHM, Daniel M-T. Gianni M, Zelent A, Licht J,Buzyn A, MinardP, Degos L, VaretB, de The H (1999): Retinoicacid, but not arsenictrioxide,degradesthe PLZF/RARafusionprotein,without inducing terminaldifferentiationor apoptosis. in a RA-therapyresistantt( I 1 ;17)(q23;q2I ) APL patient. Oncogene 18:I 1 13-1 118. Kong X-T, Ida K, Ichikawa H, Shimizu K, Ohki M, Maseki N, Kaneko Y, Sako M, KobayashiY, Tojou A, Miura 1, Kakuda H, Funabiki T, Horibe K, Hamaguchi H, Akiyama Y, Bessho F, YanagisawaM, Hayashi Y ( 1997): Consistentdetectionof TLSIFUS-ERG chimerictranscriptsin acute myeloid leukemia with t( I 6 2 I)(pl I ;q22) and identificationof a novel transcript.Blood 90:1192-1199. KozuT, Miyoshi H, Shimizu K, MasekiN, KanekoY, Asou H, KamadaN,Ohki M ( 1993):Junctionsof the AMLI/MTG8(ETO) fusion areconstant in t(8;2 1 ) acute myeloid leukemiadetected by reverse transcriptionpolymerasechain reaction. Blood 82: 1270-1 276. KrivtsovAV, ArmstrongSA (2007): MLL translocations,histone modificationsand leukaemiastemcell development. Nar Rev Cancer 7:823-833. Kusec R, Laczika K, Knob1P, Fried1J, Greinix H, Kahls P, LinkeschW, SchwarzingerI, Mitterbauer G, PurtscherB, Haas OA, LechnerK, JaegerU (1994): AMLI/ETO fusion mRNA can be detected in remissionblood samplesof all patientswith t(8;2 I ) acutemyeloid leukemiaafterchemotherapy or autologous bone marrowtransplantation.Leukemia 8:735-739. Kwong Y-L, PangA ( 1999):Low frequencyof rearrangementsof thehomeobox gene HOXA9/t(7;1I ) in adult acute myeloid leukemia. Genes Chromosomes Cuncer 25370-74. LahortigaI, Agirre X, Belloni E, Vdzquez I, Larrayoz MJ, Gasparini P, Lo COCOF, Pelicci PG, CalasanzMJ, OderoMD (2004a): Molecularcharacterizationof at(1 ;3)(p36;q21)in a patientwith MDS. MELI is widely expressed in normal tissues. including bone marrow, and it is not overexpressed in the t( 1;3) cells. Oncogene 23:311-316. LahortigaI, V h u e z 1, Agirre X, LarrayozMJ, Vizmanos JL, Gozzetti A, Calasanz MJ, OderoMD (2004b): Molecular heterogeneity in AMLMDS patients with 3q2 1q26 rearrangements.Genes Chromosomes Cancer 40: 179-1 89. Lai J-L, PreudhommeC, ZandeckiM, Flactif M, VanrumbekeM, Lepelley P, Wattel E, Fenaux P (1995): Myelodysplastic syndromesand acute myeloid leukemia with 17p deletion. An entity characterizedby specific dysgranulopoiesis and a high incidence of P53 mutations. Leukemia 9~370-38I . Lam DH, Aplan PD (2001): NUP98 gene fusions in hematologic malignancies. Leukemia 15:1689- 1695. LampertF, HarbottJ, RitterbachJ (199 I): Chromosomenaberrationenbei akuten Leukamien im Kindesalter:Analyse von 1009 Patienten.Klin Padiatr 203:3 I 1-318. LangabeerSE, GrimwadeD, WalkerH, RogersJR, BurnettAK, GoldstoneAH, Linch DC (1998): A study to determine whether trisomy 8, deleted 9q and trisomy 22 are markers of cryptic rearrangementsof PMURARa, AMLUETO and CBFWMYHII respectively in acute myeloid leukaemia. Br J Huematol 10I :338-340. LangabeerSE, RogersJR,HarrisonG , WheatleyK, WalkerH, Bain BJ, BumettAK, Goldstone AH, Linch DC,Grimwade D (2001): EVll expression in acute myeloid leukaemia. Br J Huematol 112:208-211. LarsonRA, Le Beau MM, VardimanJW,Testa JR, Golomb HM, Rowley JD (1983): The predictive value of initial cytogenetic studiesin 148 adultswith acute nonlymphocyticleukemia:a 12-year study (1970- 1982). Cancer Genef Cytogenet 10:2 19-236. LarsonRA, Kondo K, VardimanJW. Butler AE, Golomb HM, Rowley JD (1984): Evidence for a 15;17 translocation in every patient with acute promyelocytic leukemia. Am J Med 76:827-841.

REFERENCES

119

La StarzaR, Stella M. Testoni N, Di Bona E, Ciolli S, MarynenP, MartelliMF, MandelliF, Mecucci C (1999): Characterizationof 12p molecularevents outside ETV6 in complex karyotypesof acute myeloid malignancies. Er J Haematol107:340-346. La StarzaR, Crescenzi B, KrauseA, Pierini V, Specchia G, Bardi A, Nieddu R, Ariola C, Nanni M, Diverio D, Aventin A, SborgiaM, MartelliMF, BohlanderSK, Mecucci C (2006):Dual-color split signal fluorescence in situ hybridizationassays for the detectionof CALWAFIOin t( 10;1 L)(p13; q 14-q2I)-positive acute leukemia. Haematologica91: 1248-125 1. LavauC, Szilvassy SJ, SlanyR, ClearyML (1997): lmmortalizationand leukemic transformationof a myelomonocytic precursorby retrovirallytransducedHRX-ENL. EMBOJ I 6:4226-4237. Le Beau MM, LarsonRA, Bitter MA, VardimanJW,Golomb HM, Rowley JD (1 983): Association of an inversion of chromosome 16 with abnormal marroweosinophils in acute myelomonocytic leukemia. N Engl J Med 309:630-636. Le Beau MM, WestbrookCA, Diaz MO, Rowley JD (1985): c-src is consistently conserved in the chromosomal deletion (2Oq) observed in myeloid disorders. Proc Natl Acad Sci USA 82:66924696. Le Beau MM, Albain KS, LarsonRA, VardimanJW, Davis EM, Blough RR, GolombHM, Rowley JD ( 1986):Clinical and cytogenetic correlationsin 63 patientswith therapy-relatedmyelodysplastic syndromesand acutenonlymphocyticleukemia:furtherevidence for characteristicabnormalities of chromosomes No. 5 and 7. J Clin Oncol4:325-345. Le Beau MM, Epstein ND, OBrien SJ, Nienhuis AW, Yang Y-C, ClarkSC, Rowley JD (1987):The interleukin3 gene is located on humanchromosome5 and is deleted in myeloid leukemias with a deletion of 5q. Proc NatlAcad Sci USA 845913-5917. Le Beau MM, EspinosaR 111, Davis EM, EisenbartJD, LarsonRA, GreenED ( 1996): Cytogeneticand molecular delineation of a region of chromosome 7 commonly deleted in malignant myeloid diseases. Blood 88:1930-1935. Leith CP, Kopecky KJ. Godwin J, McConnell T, Slovak ML, Chen IM, Head DR, AppelbaumFR, Willman CL (1997): Acute myeloid leukemia in the elderly: assessment of multidrugresistance (MDRI) andcytogenetics distinguishesbiologic subgroupswith remarkablydistinctresponsesto standardchemotherapy.A SouthwestOncology Groupstudy. Blood 893323-3329. Levy ER, ParganasE, MorishitaK, Fichelson S, JamesL, Oscier D, GisselbrechtS, IhleJN, Buckle VJ (1994):DNA rearrangementsproximalto the EVIl locus associatedwith the 3q21q26syndrome. Blood 83:1348-1354. Li J, Bench AJ, VassiliouGS, FourouclasN, Ferguson-SmithAC, Green AR (2004): Imprintingof the humanL3METL gene, a polycombfamily memberlocatedin a regionof chromosome20 deletedin human myeloid malignancies. Proc Natl Acad Sci USA 101:7341-7346. Liang H, FairmanJ, Claxton DF, Nowell PC, Green ED, NagarajanL (1998): Molecularanatomyof chromosome 7q deletions in myeloid neoplasms: evidence for multiple critical loci. Proc Natl Acad Sci USA 95:3781-3785. Licht JD, ChomienneC, Goy A, Chen A, Scott AA, Head DR, Michaux JL, Wu Y,DeBlasio A, Miller WH Jr, Zelenetz AD, Willman CL, Chen 2. Chen S-J, Zelent A, MacintyreE, Veil A, Cortes J, KantarjianH, Waxman S (1995): Clinical and molecular characterizationof a rare syndrome of acute promyelocytic Leukemia associated with translocation (1 1 ;17). Blood 85: 1083-1094. Lie SO, AbrahamssonJ, Clausen N, ForestierE, Hasle H. Hovi L, JonmundssonG, MellanderL, Gustafsson G (2003):Treatmentstratificationbased on initial in vivo response in acute myeloid leukaemiain children without Down’s syndrome:results of NOPHO-AML.trials. Br J Haematol 122:217-225. Lillington DM, Young BD, Berger R, MartineauM, Moorman AV, Secker-WalkerLM (1998): The t( 1 0 1 I )(p 12;q23)translocationin acuteleukaemia:a cytogeneticandclinical studyof 20 patients. Leukemia 12901-804.

120

ACUTE MYELOID LEUKEMIA

LionT,HaasOA, HarbottJ,BannierE, RitterbachJ. JankovicM, FinkFM,StojimixovicA, Herrmann J, RiehmHJ,LampertF, RitterJ, Koch H, GadnerH ( 1992):The translocationt( I ;22)(p13;q13) is a nonrandommarkerspecificallyassociatedwith acutemegakaryocyticleukemiain young children. Blood 79:3325-3330. Liso V, BennettJ (2003): Morphologicaland cytochemicalcharacteristicsof leukaemicpromyelocytes. Best PractRes Clin Haematol 16:349-355. LitmanovichD,Zamir-BrillR,JeisonM,Gershoni-BaruchR(2000):Is inversion16aprerequisiteandis trisomy 22 invariablyassociated with inversion 16 in AML-M4eo? Cancer Genet Cytogenet 121:106. Liu P, Tar16SA, HajraA, ClaxtonDF, MarltonP, FreedmanM, SicilianoMJ, CollinsFS ( I 993): Fusion between transcriptionfactorCBFB/PEBP2Panda myosinheavy chainin acutemyeloidleukemia. Science 26 1 :1041-1 044. LiuTX, BeckerM W ,JelinekJ, Wu W-S, Deng M, MikhakevichN, HsuK, BloomfieldCD, StoneRM, DeAngelo DJ, GalinskyIA, Issa JP, ClarkeMF. Look AT (2007): Chromosome5q deletion and epigenetic suppressionof the gene encoding alpha-catenin(CTNNAI)in myeloid cell transformation.Nat Med 13:7&83. Lo CocoF, DiverioD, FaliniB, BiondiA, NerviC, Pelicci PG( 1999):Geneticdiagnosisandmolecular monitoringin the managementof acute promyelocyticleukemia.Blood 94: 12-22. LongoL, PandolfiPP,Biondi A, RambaldiA, MencarelliA, Lo Coco F, DiverioD, PegoramL, Avanzi G, TabilioA, ZangrilliD, Alcalay M, DontiE, GrignaniF, Pelicci PG (1990): Rearrangements and aberrantexpressionof the retinoicacid receptora gene in acute promyelocyticleukemias.J Exp Med 172:1571-1575. Ma SK,Lie AKW, Au WY, WanTSK,ChanLC ( 1997):CD7 + acutemyeloidleukaemiawith 'mature lymphoid'blastmorphology,marrowbasophiliaandt(4;12)(q12;pl3).BrJHaematol97:978-980. Ma Z, Moms SW, ValentineV, Li M, HerbrickJ-A, Cui X, Bouman D, Li Y, MehtaPK, Nizetic D, KanekoY. Chan GCF,ChanLC, SquireJ, SchererSW, HitzlerJK (2001): Fusion of two novel leukemia.Nut Genet genes, RBMI.5andMKLZ,in the t(1;22)(p13;q13) of acutemegakaryoblastic 28:22&22 I . MacGroganD, KalakondaN, Alvarez S, ScanduraJM, Boccuni P, JohanssonB, Nimer SD (2004): Structuralintegrityand expressionof the WMBTLgene in normaland malignanthematopoietic cells. Genes ChromosomesCancer41:203-2 13. MadrigalI, CarrioA, Gomez C, Rozman M, Esteve J, Nomdedeu B, Campo E, Costa D (2006): Fluorescencein situ hybridizationstudiesusing BAC clones of the EVZl locus in hematological malignancieswith 3q rearrangements.CancerGenet Cytogenet 170:115-120. MandelliF, DiverioD, AvvisatiG, LucianoA, BarbuiT, BernasconiC, BrocciaG, CerriR. FaldaM, FioritoniG , Leoni F, Liso V, Petti MC, RodeghieroF, Saglio G, Vegna ML, Visani G, Jehn U, Willemze R, Muus P, Pelicci PG, Biondi A, Lo Coco F ( 1 997): Molecularremissionin P W RARa-positiveacutepromyelocyticleukemiaby combinedall-transretinoicacid and idarubicin (AIDA) therapy.Blood 90:1014-1021. MarcucciG, MrozekK,RuppertAS, MaharryK,KolitzJE,Moore JO,MayerRJ,PettenatiMJ,Powell SchifferCA, CarrollAJ,LarsonRA, Bloomfield CD BL, EdwardsCG, SterlingU,VardimanJW, (2005): Prognosticfactorsand outcome of core binding factoracute myeloid leukemiapatients with t(8;21) differ from those of patientswith inv(l6): a Cancerand LeukemiaGroupB study. J Clin Oncol23:5705-57 17. MareniC, SessaregoM,OrigoneP, DeffemariR,FrassoniF, AjmarF (1989): Molecularanalysisof Philadelphia-negativemyeloprolifexativesyndromes with i( 17q). Cancer Genet Cytogenet 43:195-201. MarltonP, Claxton DF, Liu P, Estey EH, Beran M, LeBeau M, Testa JR, Collins FS, Rowley JD, Siciliano MJ (1 995a): Molecularcharacterizationof 16p deletions associated with inversion 16 defines the critical fusion for leukemogenesis.Blood 85:772-779.

REFERENCES

121

MarltonP, Keating M, KantarjianH, Pierce S, O'Brien S, FreireichEJ, Estey E (1995b): Cytogenetic and clinical correlates in AML patients with abnormalities of chromosome 16. Leukemia 9~965-971. MarosiC, KollerU, Koller-WeberE, SchwarzingerI, SchneiderB, JagerU, Vahls P,Nowotny H, PircDanoewinata H, Steger G . KreinerG, Wagner B, Lechner K, Lutz D, Bettelheim P, Haas OA ( I 992): Prognostic impact of karyotypeand immunologic phenotype in 125 adult patients with dr. n o w AML. Cancer Genet Cyfogenet 6 1 :14-25. MartineauM, Berger R, Lillington DM, MoormanAV, Secker-WalkerLM (1998): The t(6; 1 l)(q27; q23) translocation in acute leukemia: a laboratoryand clinical study of 30 cases. Leukemia 12:788-791. MartinelliG , OttavianiE, Buonamici S , lsidori A, BorsaruG , Visani G, Piccaluga PP, Malagola M, Testoni N, Rondoni M, Nucifora G , Tura S, Baccarani M (2003): Association of 3q21q26 syndromewith differentRPNI/EVII fusion transcripts.Haemafologica88:1221-1228. Martinez-ClimentJA, Lane NJ, RubinCM, MorganE, JohnstoneHS, Mick R, MurphySB, Vardiman JW,Larson RA, Le Beau MM, Rowley JD (1995): Clinical and prognostic significance of chromosomalabnormalitiesin childhood acute myeloid leukemia de novo.Leukemia 9:95-101, Massaad L, PrieurM, LeonardC, Dutrillaux B (1990): Biclonal chromosomeevolution of chronic myelomonocytic leukemia in a child. Cancer Genet Cytogenet 44: 131-1 37. Matsuda A, Jinnai 1, Yagasaki F. It0 Y, It0 K, KusumotoS, MurohashiI, Bessho M,HirashimaK (2000): The pathogenetic mechanism of myeloid malignancies associated with deletions of the long arm of chromosome20 cannotbe explained by a "onehit" model. An acutemyeloid leukemia patient who developed with 20q- clone duringcomplete remission for 9 years. Eur J Haematol 65:21&211. MauritzsonN, Albin M, RylanderL, BillstromR, AhlgrenT,MikoczyZ, BjorkJ, StrombergU, Nilsson PG, MitelmanF, HagmarL, JohanssonB (2002): Pooledanalysisof clinical andcytogeneticfeatures in treatment-relatedand de nova adult acute myeloid leukemia and myelodysplasticsyndromes based on a consecutive series of 761 patientsanalyzed 1976-1993 and on 5098 unselectedcases reportedin the literature1974-2001. Leukemia 162366-2378, Mecucci C, VermaelenK, Kulling G, MichauxJL, Noens L, A, Van Hove W, TricotG, Louwagie A, Van Den BergheH (1984): Lnterstitial9q- deletions in hematologic malignancies.Cancer Genet Cytogenet 12:309-3 19. Mecucci C, Bosly A, Michaux J-L, Broeckaert-VanOrshovenA, Van Den Berghe H (1985): Acute nonlymphoblasticleukemia with bone marroweosinophilia and structuralanomaly of chromosome 16. Cancer Genet Cytogenet 17:359-363. Mecucci C, Van OrshovenA, TricotG, MichauxJ-L,Delannoy A, Van Den Berghe H ( 1986):Tnsomy 4 identifies a subset of acute nonlymphocyticleukemias. Blood 67: 1328-1332. Megonigal MD, RappaportEF,Jones DH, WilliamsTM, Lovett BD, Kelly KM, LerouPH,MoultonT, BudarfML. Fetix CA (1998): t( 1I ;22)(q23;qll.2) in acutemyeloid leukemiaof infanttwins fuses MLL with hCDCrel, a cell division cycle gene in the genomic region of deletion in DiGeorge and velocardiofacial syndromes. Proc Natl Acad Sci USA 95:6413-6418. Mehta AB, Bain BJ, Fitchett M, Shah S, Secker-WalkerLM (1998): Trisomy 13 and myeloid malignancy-characteristic blastcell morphology:a United KingdomCancerCytogeneticsGroup survey. Br J Haematol 101:749-752. MercherT, Busson-Le ConiatM, Monni R, MauchauffeM, Khac FN,Gressin L, MugneretF. Leblanc T,Dastugue N, Berger R, Bernard OA (2001): Involvement of a human gene related to the Drosophilu spen gene in the recurrentt( I ;22) translocationof acute megakaryocyticleukemia. Proc Nail Acad Sci USA 98:577&5779. Merlat A, Lai JL, SterkersY, Demory JL, Bauters F, PreudhommeC, Fenaux P (1999): Therapyrelated myelodysplasticsyndromeandacute myeloid leukemiawith 17p deletion. A reporton 25 cases. Leukemia I3:250-257.

122

ACUTE MYELOIO LEUKEMIA

MertensF, JohanssonB, MitelmanF (1994): Isochromosomesin neoplasia.Genes Chromosomes Cancer 10221-230. MerzianuM, MedeirosLJ,CortesJ, Yin C, Lin P, JonesD, GlassmanA, KantarjianH, Huh Y (2005): inv(16)(p13q22)in chronicmyelogenousleukemiain blastphase: a clinicopathologic,cytogenetic, and molecularstudy of five cases. Am J CIin Pathol 1242307-814. MeyerC, SchneiderB, ReichelM, AngermuellerS, StrehlS, SchnittgerS, SchochC, JansenMWJC, van DongenJJ,PietersR, HaasOA, DingermannT, KlingebielT, MarschalekR (2005):Diagnostic tool for the identificationof MLL rearrangements includingunknownpartnergenes. Proc Natl Acad Sci USA 102:449-454. MeyerC, SchneiderB, JakobS, StrehlS, AttarbaschiA, SchnittgerS, Schoch C, JansenMWJC,van DongenJJM,den Boer ML,PietersR, EnnasM-G, AngelucciE, KoehlU, GreilJ,GriesingerF, zur StadtU, EkkertC, SzczepanskiT, Niggli FK, SchiferBW, KempskiH, BradyHJM,ZunaJ,TrkaJ, NigroLL, Biondi A, Delabesse E, MacintyreE. StanullaM, SchrappeM, HaasOA, BurmeisterT, DingermannT, Klingebiel T, MarschalekR (2006): The MLLrecombinomeof acuteleukemias. Leukemia 20:777-784. MichauxL, Wlodarska1, Stul M, DierlammJ, MugneretF,HerensC,BeverlooB,VerhestA, VerellenDumoulinC, Verhoef G , Selleslag D, MadoeV, LecomteM, DeprijckB, FerrantA, DelannoyA, MarichalS, DuhemC, DicatoM, HagemeijerA (2000): MLL amplificationin myeloidleukemias:a study of 14 cases with multiplecopies of 1 lq23. Genes Chromosomes Cancer 29:40-47. MielcarekM, BryantE, LokenM, ZauchaJM,Torok-StorbB. StorbR (2006): Long-termengraftment and clonal dominanceof donor-deriveddel(20q) hematopoieticcells after allogeneic stem cell Blood 107:1732- 1733. transplantation. MinamihisamatsuM, lshiharaT ( I 988): Translocation(8;2I ) andits variantsin acutenonlymphocytic leukemia.The relativeimportanceof chromosomes8 and 21 to the genesis of the disease.Cancer Genet Cytogenet 33:161-1 73. MitaniK, Sat0Y,KobayashiY, ShibasakiY,KasugaM, InabaT,HayashiY,MiuraY,MiyazonoK, Hirai H, Urabe A, TakakuF (1989): Heterogeneityin the breakpointsof chromosome19 among acute leukemicpatientswith the t(l1;19)(q23;p13) translocation.Am J Hematol31:253-257. MitelmanF,LevanG (1978): Clusteringof aberrationsto specificchromosomesin humanneoplasms. 111. Incidenceand geographicdistributionof chromosomeaberrationsin 856 cases. Hereditas 89:207-232, Mitelman F, Brandt L, Levan G (1973): Identificationof isochromosome 17 in acute myeloid leukaemia.Lancet 2:972. Mitelman F, Nilsson PG, BrandtL, Alimena G, Gastaldi R, DallapiccolaB (1981): Chromosome pattern,occupation,andclinicalfeaturesin patientswithacutenon-lymphocyticleukemia.Cancer Genet Cytogenet 4:197-214. MitelmanF, JohanssonB, MertensF (2007): The impactof translocationsand gene fusionson cancer causation.Nat Rev Cancer 7:233-245. MitelmanF, JohanssonB, MertensF (2008): MitelmanDatabaseof ChromosomeAberrationsin Cancer.Available at http://cgap.nci.nih.gov/Chromosomes/Mitelman MitterbauerM,LaczikaK, Novak M,Mitterbauer G, HilgarthB, Pirc-Danoewinata H, Schwarzinger1, HaasOA, FonatschC, LechnerK, JaegerU (2000): High concordanceof karyotypeanalysisand RT-PCRforCBFbetalMYHI 1 in unselectedpatientswithacutemyeloidleukemia.A singlecenter study.Am J Cfin Puthof I I 3 : W 10. Miyoshi H, Shimizu K, Kozu T, Maseki N, Kaneko Y, Ohki M (1991): t(8;21) breakpointson chromosome21 in acute myeloid leukemiaare clusteredwithin a limitedregion of a single gene, AMLl.Proc Natl Acad Sci USA 88: 10431-10434. MochizukiN, ShimizuS, NagasawaT, TanakaH, TaniwakiM, YokotaJ, MorishitaK (2000): A novel gene, MELI, mappedto lp36.3 is highly homologousto the MDSUEVII gene and is transcriptionally activatedin t( 1 ;3)(p36;q21)-positive leukemiacells. Blood 963209-32 14.

REFERENCES

123

MohamedAN, PembertonP, ZonderJ, SchifferCA (2003): The effect of imatinibmesylate on patients with Philadelphiachromosome-positivechronicmyeloid leukemiawith secondarychromosomal aberrations.Clin Cancer Res 9: 1333-1337. Moir DJ, Jones PAE, PearsonJJ, Duncan JR,Cook P, Buckle VJ ( 1984): A new translocation,t( 1 :3) (p36;q21 ), in myelodysplastic disorders.Blood 64553-555. MoormanAV, HagemeijerA, CharrinC, RiederH, Secker-WalkerLM ( 1 998): The translocations,t (ll:l9)(q23;p13.1) and t(l1;19)(q23:p13.3): a cytogenetic and clinical profile of 53 patients. Leukemia 12:805-8 10. MoormanAV, Roman E, CartwrightRA, MorganGJ (2002): Smoking and the risk of acute rnyeloid leukaemia in cytogenetic subgroups.Br J Cancer 86:60-62. MorishitaK, ParganasE, William CL,WhittakerMH, DrabkinH, OvalJ, TaetleR, ValentineMB, Ihle JN (1992): Activation of EVII gene expression in human acute myelogenous leukemias by translocationsspanning300-400 kilobases on chromosomeband 3q26. Proc Natl Acad Sci USA 89:3937-394 I . Morse H, Hays T, Peakman D, Rose B, Robinson A (1979): Acute nonlymphoblastic leukemia in childhood. High incidence of clonal abnormalities and nonrandom changes. Cancer 44: 164-170. Mr6zekK, Heinonen K, LawrenceD, Carroll AJ, KoduruPRK, Rao KW, StroutMP, Hutchison RE, Moore JO. Mayer RJ, Schiffer CA, Bloomfield CD (1997): Adult patients with de novo acute myeloid leukemia and t(9;l l)(p22:q23) have a superioroutcome to patientswith othertranslocations involving band 1 lq23: a Cancer and LeukemiaCroupB Study. Blood 90:45324538. &zek K, HeinonenK, Theil KS, Bloomfield CD (2002): Spectralkaryotypingin patientswith acute myeloid leukemia and a complex karyotype shows hidden aberrations, including recurrent overrepresentationof 2 Iq, 1 Iq, and 22q. Genes Chromosomes Cancer 34: 137-153. Mr6zek K, Marcucci G , Paschka P, Whitman SP, Bloomfield CD (2007): Clinical relevance of mutationsandgene-expressionchangesin adultacutemyeloid leukemiawith normalcytogenetics: are we ready for a prognostically prioritizedmolecular classification? Blood 109:431-448. Miiller CI, EngelhardtM, LaubenbergerI, KunzrnannR, EngelhardtR, LiibbertM (2002): Myelodysplastic syndrome in transformationto acute myeloid leukemia presenting with diabetes insipidus:dueto pituitaryinfiltrationassociationwith abnormalitiesof chromosomes3 and7. EurJ Haematol69 1 15- 1 19. Munoz L, NomdedCuJF, Villamor N, GuardiaR, Colomer D, Ribera JM, TorresJP, Berlanga JJ, FernandezC, Llorente A, Queipo de Llano MP. Sanchez JM, Brunet S, SierraJ (2003): Acute rnyeloidleukemia with MLL rearrangements:clinicobiological features, prognostic impact and value of flow cytometry in the detection of residual leukemic cells. Leukemia 17: 76-82. Najfeld V, Seremetis S. Troy K, Uehlinger J, Schwartz P, Cutmer J (1986): Trisomy 22-a new abnormality found in acute leukemia characterized by eosinophilia and monocytoid blasts expressing immaturedifferentiationantigens. Cancer Genet Cytogenel 23: 105-1 14. NakamuraT (2005): N U B 8 fusion in human leukemia: dysregulation of the nuclear pore and homeodomain proteins.Int J Hemaiol82:21-27. NakamuraT, Alder H, Gu Y,PrasadR, Canaani0, KamadaN, Gale RP, Lange B, Crist WM, Nowell PC, Croce CM, Canaani E (1993): Genes on chromosomes 4. 9 and 19 involved in I lq23 abnormalitiesin acute leukemiasharesequencehomology and/orcommon motifs. Proc NatlAcad Sci USA 90:463 1-4635. NakamuraT, LargaespadaDA, Lee MP, JohnsonLA,OhyashikiK, ToyamaK, Chen SJ, WillmanCL, Chen I-M. FeinbergAF', Jenkins NA, Copeland NG, Shaughnessy JD Jr (1996): Fusion of the nucleoporingene NUP98 to HOXA9 by the chromosometranslocationt(7;l I)(p15;p15) in human myeloid leukaemia. Nut Genet 12: 154-158. NakamuraH, KuriyamaK, SadamoriN, Mine M, ItoyamaT, SasagawaI, MatsumotoK, TsujiY,Asou N, KageyamaS-I,SakamakiH, Emi N. OhnoR, TomonagaM ( 1997): Morphologicalsubtypingof

124

ACUTE MYELOID LEUKEMIA

acute myeloid leukemia with maturation(Ah4L-M2): homogeneous pink-colored cytoplasm of matureneutrophilsis most characteristicof AML-M2 with t(8;21). Leukemia 11:651-655. Naoe T, Suzuki T, Kiyoi H, Urano T (2006): Nucleophosmin: a versatile molecule associated with hematologicalmalignancies. CancerSci 97:%3-969. NebralK, Konig M, SchmidtHH, Lutz D, Sperr WR,KalwakK, BruggerS, DworzakMN, HaasOA, StrehlS (2005): Screening for NUP98 rearrangementsin hematopoieticmalignanciesby fluorescence in situ hybridization.Haematologica90~746-752. NederlofPM, van derFlierS, RaapAK, TankeHJ, van derPloeg M, KornipsF, GeraedtsJPM(1989): Detection of chromosome aberrations in interphase tumor nuclei by nonradioactive in situ hybridization.Cancer Genet Cytogenel 42537-98. Nguyen S, Leblanc T, Fenaux P, Witz F, Blake D, Pigneux A, Thomas X, Rigal-HuguetF, Lioure B, Auvrignon A, Fikre D, Reiffers J, Castaigne S, Leverger G, Harousseau J-L, SociC G, Dombret H (2002): A white blood cell index as the main prognostic factor in t(8;21) acute myeloid leukemia (AML): a survey of 161 cases from the French AML Intergroup.Blood 99:35 17-3523. Niemeyer MMG, HaakHL, AugustinusE, den Nijs-van WeertJ1, LeeksmaCHW (1986):Trisomyof chromosome 22 in acute myelomonocytic leukemia. CancerGenet Cytogenef 20:37 1-374. NienhuisAW, Bunn HF,TurnerPH, GopalTV, Nash WG, O'Brien SJ, SherrCJ (I985): Expressionof the humanc-fmr proto-oncogenein hematopoieticcells andits deletion inthe 5q- syndrome.Cell 4 2 4 2 1-428. Nilsson B (1984): Probablein vivo induction of differentiationby retinoic acid of promyelocytesin acute promyelocytic leukaemia. Br J Haematol57:365-37 I. Nishii K, Usui E, KatayamaN, LorenzoF5th, NakaseK, KobayashiT, Miwa H, MizutaniM, TanakaI, Nasu K, Dohy H. Kyo T, TaniwakiM, Ueda T, Kita K, Shiku H (2003): Characteristicsof t(8;21) acute myeloid leukemia(AML) with additionalchromosomalabnormality:concomitanttrisomy4 may constitutea distinctive subtype of t(8;21) AML. Leukemia 17:731-737. NogueraNI,BrecciaM, Divona M, DiverioD. CostaV, De SantisS, Avvisati G, Pinazzi MB, PettiMC, Mandelli F, Lo Coco F (2002): Alterationsof the FLT3 gene in acute promyelocytic leukemia: associationwith diagnosticcharacteristicsandanalysis of clinical outcome in patientstreatedwith the Italian AIDA protocol. Leukemia I6:2185-2 189. Nucifora G, Rowley JD (1995): AMLl and the 8;21 and 3;21 translocationsin acute and chronic myeloid leukemia. Blood 86:1-14. NuciforaG, Birn DJ, Espinosa R III, EricksonP, LeBeau MM, RoulstonD, McKeithanTW, Drabkin H. Rowley JD (1993a): Involvementof the AMLl gene in the t(3;21) in therapy-relatedleukemia and in chronic myeloid leukemia in blast crisis. Blood 81:2728-2734. Nucifora G, Larson RA, Rowley JD (1993b): Persistence of the 8;21 translocationin patientswith acute myeloid leukemia type M2 in long-term remission. Blood 82:712-715. Nucifora G , Laricchia-RobbioL. Senyuk V (2006): EVI1 and hematopoieticdisorders:history and perspectives. Gene 368:1-I I. Nusslein-VolhardC, Wieschaus E ( I 980): Mutations affecting segment number and polarity in Drosophila. Nature287:795-801. O'Brien S, KantarjianHM, Keating M, Gagnon G, Cork A, Trujillo J, McCredie KB (1989): Association of granulocytosiswith poor prognosis in patients with acute myelogenous leukemia and translocationof chromosomes8 and 21. J Clin Oncol7:1081-1086. Odero MD, Carlson K, Calasanz MJ, LahortigaI, ChinwallaV, Rowley JD (2001): Identificationof new translocationsinvolving ETV6 in hematologic malignancies by fluorescence in situ hybridization and spectralkaryotyping.Genes ChromosomesCancer3 1: 134-142. Ohyashiki K (1984): Nonrandomcytogenetic changes in human acute leukemia and their clinical implications. CancerGenet Cytogenet 1 1 :453-471.

REFERENCES

125

Ohyashiki K, Ohyashiki JH, Iwabuchi A, [to H, Toyama K (1988): Central nervous system involvement in acute nonlymphocyticleukemia with inv(l6)(p 13q22). Leukemia2:398-399. Okada M, Miyazaki T, Kumota K (1977): 15/17 translocationin acute promyelmyticleukaemia. Lancet 1:961. Olopade 01, Thangavelu M,Larson RA, Mick R, Kowal-VernA, SchumacherHR, Le Beau MM, Rowley JD (1992): Clinical, morphologic. and cytogenetic characteristicsof 26 VardimanJW, patients with acute erythroblasticleukemia. Blood 80:2873-2882. O’RiordanML, Berry EW,Tough IM (1970): Chromosomestudies on bone marrowfrom a male control population. Br J Haematol 19:83-90. OsakaM, Rowley JD, Zeleznik-LeNJ ( 1999): MSF(MLLseptin-likefusion), a fusion partnergene of MLL, in a therapy-relatedacute myeloid leukemia with a t(l1;17)(q23;q25). Proc NatZAcadSci USA 96:6428-6433. OshimuraM, HayataI, KakatiS, SandbergAA (1976): Chromosomesandcausationof humancancer andleukemia. XVII. Bandingstudiesin acute myeloblastic leukemia(AML). Cancer38:748-761. Oyarzo MP, Lin P, Glassman A, Bueso-Ramos CE, LuthraR, Medeiros LJ (2004): Acute myeloid leukemia with t(69)(p23;q34) is associated with dysplasia and a high frequency of jIt3 gene mutations.Am J Clin Pathol l22:348-358. PanagopoulosI, h a n P, Fioretos T, Hoglund M, Johansson B, MandahlN, Heim S, BehrendtzM, Mitelman F (1994): Fusion of the FUS gene with ERG in acute myeloid leukemia with t( 16;21) (pl 1 ;q22). Genes ChromosomesCancer I 1 :256-262. PanagopoulosI, Isaksson M, Lindvall C, BjorkholmM, Ahlgren T, Fioretos T, Heim S, Mitelman F, Johansson B (2000): RT-PCR analysis of the MOZ-CBP and CBP-MOZ chimeric transcriptsin acute myeloid leukemias with t(8; 16)(pI l;p13). Genes ChromosomesCancer 28:4 15-424. Panagopoulos [, FioretosT,IsakssonM,LarssonG, Billstrom R,Mitelman F, JohanssonB (2002): Expression of NUP98mOP1, but not of TOPUNUP98, in a treatment-relatedmyelodysplastic syndrome with t( 10;20;1 l)(q24;ql1;p15). Genes ChromosomesCancer34:249-254. PanagopoulosI, Kitagawa A, Isaksson M, Morse H, MitelmanF, JohanssonB (2004): MLLIGRAF fusion in an infantacute monocytic leukemia(AML M5b) with a cytogenetically crypticins(5; 11) (931;q23q23). Genes ChromosomesCancer41 :400-404. PanarelloC,RosandaC, MorerioC (2002): Cryptictranslocation t(5;1 l)(q35;p15.5) with involvement of the NSDl and NUP98 genes without 5q deletion in childhood acute myeloid leukemia. Genes ChromosomesCancer35:277-28 1. ParkKU, Lee DS, Lee HS, Kim CJ,ChoHI (2001): Granulocyticsarcomain MLLpositive infantacute myelogenous leukemia.Fluorescence in situ hybridizationstudy of childhood acute myelogenous leukemia for detecting MLL rearrangement.Am J Pathol 159:2011-2016. ParkinJL, ArthurDC, AbramsonCS, McKennaRW, KerseyJH, HeidemanRL, BrunningRD (1 982): Acute leukemia associated with the t(4;1 1 ) chromosome rearrangement:ultrastructuraland immunologic characteristics.Blood 60.132 1-1 331. Paschka P, Marcucci G, RuppertAS, Mr6zek K, Chen H, Kittles RA. Vukosavljevic T, PerrottiD, VardimanJW, Carroll AJ, Kolitz JE, Larson RA, Bloomfield CD (2006): Adverse prognostic significanceof KITmutationsin adult acute myeloid leukemiawith inv( 16) and t(8;21): a Cancer and Leukemia Group B study.J Clin Oncol24:3904-39 I 1. Paulsson K, JohanssonB (2007): Trisomy 8 as the sole chromosomal aberrationin acute myeloid leukemia and myeiodysplastic syndromes. PatholBiol55:3748. PaulssonK, HeidenbladM, StrijmbeckB, StaafJ, JonssonG, Borg .&FioretosT, JohanssonB (2006): High-resolution genome-wide array-basedcomparativegenome hybridization reveals cryptic chromosomechangesin AML and MDS cases with trisomy 8 as the sole cytogenetic aberration. Leukemia20:840-846.

126

ACUTE MYELOID LEUKEMIA

Pearson MG, VardimanJW, Le Beau MM, Rowley JD, Schwartz S, Kerman SL, Cohen MM, FleischmanEW, PrigoginaEL ( 1985): Increasednumbersof m m w basophilsmay be associated with a t(6;9) in ANLL. Am J Hematol lk393-403. Pedersen B (1992a): Survival of patientswith t(1;7)(plI;pll).CancerGenet Cytogenet6053-59. PedersenB (I 992b): Trisomy4: clinicalpicture,hematology,andsurvival.Presentationof two cases and review of the literature.HematolPathol6:161-167. PedersenB, JensenIM ( 199la): Clinicalandprognosticimplicationsof chromosomeSq deletions:96 high resolutionstudiedpatients.Leukemia5566-573. PedersenB, JensenIM ( 1991b): Trisomy 13: a preferentiallymalechromosomeaberrationinterfering specifically with myeloid proliferationand differentiation?Reportof a case and review of the literature.CancerGenet Cytogemt57:79-85. Pedersen-BjergaardJ, Philip P ( 1987): Cytogenetic characteristicsof therapy-relatedacute non1ymphocyticleukaemia,preleukaemiaand acute myeloproliferativesyndrome:correlationwith clinical datafor 6 I consecutivecases. Br J Haematol66:199-207. Pedersen-Bjergaard J, Philip P, Ravn V, Hansen SW, Nissen NI (1988): Therapy-relatedacute nonlymphocyticleukemiaof FAB type M4 or M5 with early onset and t(9;ll) (p21;q23) or a normalkaryotype:a separateentity?J Clin Oncol6395-397. Pedersen-Bjergaard3, Philip P, Olesen Larsen S , Jensen G, Byrsting K (1990): Chromosome aberrationsand prognosticfactorsin therapy-relatedmyelodysplasiaand acute nonlymphocytic leukemia.Blood 76: 1083-1091. Pedersen-Bjergaard J, JohanssonB, PhilipP ( I 994): Translocation(3;2 1)(q26;q22)in therapy-related myelodysplasiafollowing drugs targeting DNA-topoisomerase11 combined with alkylating agents, and in myeloproliferativedisordersundergoing spontaneous leukemictransformation. CancerGenet Cytogenet76:5&55. Pedersen-Bjergaard J, ChristiansenDH. Desta F, AndersenMK (2006): Alternativegenetic pathways and cooperatinggenetic abnormalitiesin the pathogenesisof therapy-related myelodysplasiaand acute myeloid leukemia.Leukemia20: 1943-1 949. PeetersP, WlodarskaI, Baens M, CrielA, SelleslagD. HagemeijerA, Van den BergheH, MarynenP (1997): Fusion of Em6 to MDSUEVIl as a result of t(3;12)(q26;p13) in myeloproliferative disorders. CancerRes 57:564-569. PekarskyY, RynditchA, WieserR, FonatschC, GardinerK ( 1997):Activationof a novel gene in 3q21 and identificationof intergenicfusion transcriptswith ecotropicviral insertionsite I in leukemia. CancerRes 57:3914-3919. PeniketA, WainscoatJ. Side L, DaIyS, Kusec R. BuckG, WheatleyK, WalkerH, ChattersS, Harrison C, Boultwood J, Goldstone A, Burnett A (2005): Del (9q) AML: clinical and cytological characteristicsand prognosticimplications.Br J Haematol129:210-220. PereaG, Domingo A, VillamorN, Palacios C, JuncaJ, TorresP, LlorenteA, FernandezC, TormoM, QueipodeLIanoMp,BargayJ,GallartM,FIorensaL,VivancosP,MartiJM,FontL, BerlangaJ,Esteve J, BuenoJ,RiberaJM,BrunetS, SierraJ, NomdedeuJF(2005): Adverseprognosticimpactof CD36 and C M expressionin adultde novo acutemyeloid leukemiapatients.Leuk Res 29: I 109-1 1 16. PetersonLF,BoyapatiA, Ahn E-Y, Biggs JR,OkumuraAJ, Lo M-C,Yan M, ZhangD-E (2007): Acute myeloid leukemiawith the8q22;21q22 translocation:secondarymutationaleventsandalternative t(8;21) transcripts.Blood 110:799-805. Petit P, AlexanderM, Fondu P (1973): Monosomy 7 in erythroleukaemia. Lancet2: 1326-1 327. PierreRV, HoaglandHC( 1972): Age-associatedaneuploidy:loss of Y chromosomefromhumanbone marrowcells with aging. Cancer30:889-894. Poppe B, Van LimbergenH, Van Roy N, VandecruysE, De PaepeA, Benoit Y,SpelemanF (2001): Chromosomalaberrationsin Bloom syndromepatientswith myeloid malignancies.CancerGenet Cytogenet 128:39-42.

REFERENCES

127

PoppeB. VandesompeleJ, Schoch C, LindvallC, Mr6zekK, BloomfieldCD, Beverloo HB, Michaux L, DastugueN, HerensC, Yigit N, De Paepe A. HagemeijerA, SpelemanF (2004): Expression analysesidentifyMLL as a prominenttargetof I I q23 amplificationandsupportanetiologicrolefor MLL gain of function in myeloid malignancies.Blood 103:229-235. Poppe B, DastugueN, VandesompeleJ, CauwelierB, Lk Smet B, Yigit N, De Paepe A,CerveraJ, RecherC, De MasV, HagemeijerA, SpelemanF(2006): EVZZ is consistentlyexpressedas principal transcriptin common and rare recurrent3q26 rearrangements.Genes Chromosomes Cancer 45 :349-3 56. Powell H, Curtis A, Bown N, Taylor P (2005): No correlationbetween trisomy 13 and FLT3 duplicationin acute myeloid leukemia.Cancer Genef Cyfogenet I 56:92-93. PrasadR, Gu Y. AlderH, NakamuraT,Canaani0,SaitoH, HuebnerK, Gale RP, Nowell PC, Kuriyama K, MiyazakiY, CroceCM, CanaaniE (1993): Cloningof the AU-I fusionpartner,the AF-6 gene, involved in acute myeloid leukemias with the t(6;JI ) chromosometranslocation.Cancer Res 535624-5628. PrasadR, LeshkowitzD, Gu Y, Alder H, NakamuraT, Saito H, HuebnerK, Berger R, Croce CM, CanaaniE (1994a):Leucine-zipperdimerizationmotif encodedby the AFJ 7 gene fused to ALL-I (MLL) in acute leukemia. Proc Nut/ Acad Sci USA 9 1 :8 107-8 I 1 I . PrasadDDK. OuchidaM, Lee L, Rao VN, Reddy ESP(1 994b):TLSBUS fusiondomainof TLSIFUSerg chimericproteinresultingfrom the t( 1 6 2 I ) chromosomaltranslocationin human myeloid leukemiafunctions as a transcriptionalactivationdomain.Oncogene 9:37 17-3729. PreudhommeC, Warot-LozeD, Roumier C, Grardel-DuflosN, GarandR, Lai JL, Dastugue N, MacintyreE, Denis C, BautersF, KerckaertJP, Cosson A, Fenaux P (2000): High incidence of biallelic point mutations in the Runt domain of the AMLl/PEBP2alphaB gene in Mo acute myeloid leukemia and in myeloid malignancies with acquired trisomy 21. Blood 96~2862-2869. PreudhommeC, Sagot C, Boissel N, CayuelaJ-M, Tigaud 1. de Botton S , ThomasX, Raffoux E, LamandinC, CastaigneS , Fenaux P, DornbretH (2002): Favorableprognosticsignificanceof CEBPA mutationsin patients with dr novo acute myeloid leukemia:a study from the Acute LeukemiaFrenchAssociation(ALFA).Blood 1002717-2723. PrigoginaEL,FleischmanEW. PuchkovaGP, KulaginaOE,MajakovaSA, BalakirevSA, FrenkelMA, Khvatova NV, Peterson IS (1979): Chromosomes in acute leukemia. Hum Genet 53: 5-16.

PuiC-H,BehmFG, RaimondiSC, Dodge RK,GeorgeSL,RiveraGK,MirroJ Jr.KalwinskyDK, Dahl GV, MurphySB, CristWM, WilliamsDL (1989): Secondaryacutemyeloid leukemiain children treatedfor acute lymphoid leukemia.N Engl J Med 321:136-142. Quesnel B. KantarjianH, PedersenBjergaardJ, Brault P, Estey E, Lai JL, Tilly H, Stoppa AM, ArchimbaudE, HarousseauJL, Bauters F, Fenaux P (1993): Therapy-relatedacute myeloid leukemiawith t(8;21 ), inv(16), andt(8;16):a reporton 25 cases andreviewof the literature.J CIin Oncol I 1:2370-2379. RaghavanM, LillingtonDM. SkoulakisS , DebernardiS, ChaplinT, Foot NJ, ListerTA. Young BD (2005): Genome-wide single nucleotide polymorphism analysis reveals frequent partial uniparentaldisomy due to somatic recombinationin acute myeloid leukemias. Cancer Res 65~375-378. RaimondiSC, Dub6 ID, ValentineMB, MirroJ Jr Watt HJ, Larson RA, BitterMA, Le Beau MM, Rowley JD (1989): Clinicopathologicmanifestationsand breakpointsof the t(3;5) in patientswith acute nonlymphocyticleukemia.Leukemia 3:4247. RaimondiSC, ChangMN, RavindranathY,Behm FG, GresikMV,SteuberCP,WeinsteinHJ,Carroll AJ (1999):Chromosomalabnormalitiesin 478 childrenwith acute myeloid leukemia:clinical characteristicsand treatmentoutcome in a cooperativePediatricOncology Groupstudy-POG 8821, Blood 94:3707-3716.

128

ACUTE MYELOID LEUKEMIA

RatainMJ,KaminerLS, BitranJD,LarsonRA, Le Beau MM, Skosey C, PurlS, HoffmanPC,WadeJ, VardimanJW, Daly K, Rowley JD, Golomb HM (1987): Acute nonlymphocytic leukemia following etoposideand cisplatincombinationchemotherapyfor advancednon-small-cellcarcinoma of the lung. Blood 70:1412-1417. Raynaud SD, Baens M, GrosgeorgeJ, Rodgers K. Reid CDL, Dainton M, Dyer M, Fuzibet JG, GratecosN, TaillanB, AyraudN, MarynenP (1996): Fluorescencein situ hybridizationanalysisof t(3;12)(q26;p13): a recurringchromosomalabnormalityinvolving the TEL gene (Ef'V6)in myelodysplasticsyndromes.BIood 88:682-689. Redei I, Mangan KF, Ming PL, Mullaney MT, Rao PN, Goldberg SL, Klumpp TR (1997): Detection of a dormant 20q-leukemiaclone in bone marrow cultures with hematopoietic growthfactors:implicationsfor secondaryleukemiapost-transplant. Bone MarrowTransplant 19~521-523. RednerRL, RushEA, FaasS, RudertWA, CoreySJ( 1 996):Thet(5;17) variantof acutepromyelocytic acid receptorfusion. Blood 87:882-886. leukemiaexpresses a nucleophosmin-retinoic RednerRL. ChenJD,RushEA, Li H, Pollock SL (2000): The t(5;17) acutepromyelocyticleukemia fusion proteinNPM-RARinteractswith co-repressorandco-activatorproteinsandexhibitsboth positive and negative transcriptionalproperties.Blood 95:2683-2690. Rege-CambrinG, GiuglianoE, MichauxL, Stul M, ScaravaglioP, SerraA, Saglio G, HagemeijerA (2005): Trisomy 11 in myeloid malignanciesis associatedwith internaltandemduplicationof both M U and FLT3 genes. Haematologica 90:262-264. Reilly JT (2005): Pathogenesisof acute myeloid leukaemiaand inv( 16)(pl3;q22):a paradigmfor understandingleukaemogenesis?Br J Haernatol 128:18-34. ReiterE, GreinixH, RabitschW, Keil F,SchwarzingerI, JaegerU, LechnerK, Wore1N, StreubelB, FonatschC, MitterbauerG, Kalhs P (2000): Low curativepotentialof bone marrowtransplantation for highly aggressiveacutemyelogenous leukemiawith inversioninv(3)(q21q26)or homologous translocationt(3;3)(q21;q26). Ann Hematol79374-377. Reiter A, LengfelderE, GrimwadeD (2004): Pathogenesis,diagnosis and monitoring of residual disease in acutepromyelocyticleukaemia.Acta Haematol2004: 1 1255-67. Riske CB, Morgan R, Ondreyco S, SandbergAA (1994): X and Y chromosomeloss as sole abnormalityin acute non-lymphocytic leukemia(ANLL). Cancer Genet Cytogenet 72:44-47. RomanaSP, Radford-WeissI, Ben AbdelaliR, SchluthC, PetitA, DastugueN, TalmantP, BilhouNaberaC, MugneretF, Lafage-PochitaloffM, MozziconacciMJ,AndrieuJ, Lai JL,TerreC, Rack K, Cornillet-Lefebvre P, LuquetI, Nadal N, Nguyen-KhacF, PerotC, Van den AkkerJ, Fert-Femr S, CabrolC, CharrinC, Tigaud1, Poirel H,VekemansM, BernardOA, BergerR (2006): NUP98 rearrangements in hematopoieticmalignancies:a studyof the GroupeFrancophonede CytogCn6tique HCmatologique.Leukemia 20:696706. Rosenthal NS, Knapp D, Farhi DC (1995): Promyelocyticblast crisis of chronic myelogenous leukemia.A raresubtypeassociatedwithdisseminatedintravascular coagulation.Am JClin Pathol 103:185-1 88. RoulstonD, Espinosa R III, Stoffel M, Bell GI, Le Beau MM (1993): Moleculargeneticsof myeloid leukemia: identification of the commonly deleted segment of chromosome 20. Blood 823424-3429. Rowley JD (1973a): Deletions of chromosome7 in haematologicaldisorders.Lancet2 1385-1386. Rowley JD (1973b): Identificationof a translocationwith quinacrinefluorescencein a patientwith acute leukemia.Ann Genet 16:109-1 12. Rowley JD (1976): 5q- acute myelogenous leukemia:reply. Blood 48:626. Rowley JD, Potter D (1976): Chromosomalbanding patternsin acute nonlymphocytic leukemia. Blood 47:705-72 1. Rowley JD,GolombHM,DoughertyC (1977): 15/17 translocation,a consistentchromosomalchange in acute promyelocyticleukaemia.Lancet 1549-550.

REFERENCES

129

Rowley JD, Reshmi S, Sobulo 0,Musvee T, AnastasiJ,RaimondiS, SchneiderNR, BarredoJC,Cantu ES, SchlegelbergerB, Behm F, Doggett NA, BorrowJ,Zeleznik-Le N ( 1997): All patientswith the t( I 1 ;16)(q23;pl3.3) that involves MLL and CBP have treatment-relatedhematologic disorders. Blood 90535-541. Rubin CM, Larson RA, Bitter MA, Carrino JJ, Le Beau MM, Diaz MO, Rowley JD (1987): Association of a chromosomal 3;2 I translocationwith the blast phase of chronic myelogenous leukemia. Blood 70:1338- 1342. RubinCM, LarsonRA, AnastasiJ, WinterJN,ThangaveluM, VardimanJW, Rowley JD,Le Beau MM (1990): t(3;2 l)(q26;q22): a recurringchromosomal abnormalityin therapy-relatedmyelodysplastic syndromeand acute myeloid leukemia. Blood 76:2594-2598. RubnitzJE, Raimondi SC, Tong X. SrivastavaDK, RazzoukB1, ShurtleffSA, Downing JR, Pui C-H, Ribeiro RC, Behm FG (2002): Favorable impact of the t(9;ll) in childhood acute myeloid leukemia. J Clin Oncol202302-2309. Russell M,List A, GreenbergP. Woodward S, GlinsmannB, ParganasE, Ihle J, Taetle R (1994): Expressionof EVI 1 in myelodysplastic syndromesand other hematologic malignancies without 3q26 translocations.Blood 84:1243-1 248. Sadamori N, Yao E, Tagawa M, NakamuraH, Sasagawa I, Itoyama T, Tokunaga S. IchimaruM. NakamuraI, KameiT, YokoyamaY ( 1990): 16;21 translocationin acutenonlymphocyticleukemia with abnormaleosinophils: a unique subtype. Acta Haematol84:212-2 16. Sainty D, Liso V, Cantu-RajnoldiA, Head D, Mozziconacci M-J. Arnoulet C, BenattarL, Fenu S, Mancini M, Duchayne E, Mahon F-X,Gutierrez N, Birg F, Biondi A, Grimwade D, LafagePochitaloff M, HagemeijerA, FlandrinG (2000): A new morphologicclassification system for acute promyelocytic leukemia distinguishescases with underlyingPLZF/RARA gene rearrangements. Blood 96: 1287-1296. SanadaM, Uike N, Ohyashiki K, Ozawa K, Lili W, Hangaishi A, KandaU,Chiba S, KurokawaM, Omine M, Mitani K, Ogawa S (2007): Unbalanced translocationder(1 ;7)(q 1O;plO)defines a unique clinicopathologicalsubgroupof myeloid neoplasms. Leukemia 21 :992-997. Sandberg AA, Sakurai M (1973): The missing Y chromosome and human leukaemia. Lancet 1:37S. Sanderson RN, Johnson PRE, MoormanAV, Roman E, Willett E, Taylor PR, ProctorSJ, Bown N, Ogston S, Bowen DT (2006):Population-baseddemographicstudy of karyotypesin 1709 patients with adult acute myeloid leukemia. Leukemiu20:444-450. Sandler DP, Shore DL, Anderson JR, Davey FR, Arthur A, Mayer RJ, Sliver RT, Weiss RB, Moore JO, Schiffer CA, Wurster-Hill DH, Mclntyre OR, Bloomfield CD (1993): Cigarette smoking andrisk of acuteleukemia: associations with morphologyand cytogenetic abnormalities in bone marrow.J Natl CancerInsl 851994-2003. Sasaki M, Muramoto J, Makino S, Hara Y, Okada M, Tanaka E (1975): Two cases of acute myeloblastic leukemia associated with a 9/22 translocation.Proc Jpn Acad 5 1:193-1 97. Sasaki M, OkadaM, Kondo I, MuramotoJ (1976): Chromosomebandingpatternsin 27 cases of acute myeloblastic leukemia. Proc Jpn Acad 52:SOS-508. Sasaki M, Kondo K, Tomiyasu T (1983): Cytogenetic characterizationof ten cases of Phl-positive acute myelogenous leukemia. Cancer Genet Cytogenef 9: I 19-128. SatakeN, MasekiN. NishiyamaM, KobayashiH, SakuraiM, InabaH, KatanoN, HorikoshiY, Eguchi H, Miyake M, Set0 M, KanekoY ( 1999): ChromosomeabnormalitiesandMLL rearrangementsin acute rnyeloid leukemiaof infants. Leukemia 13:1013-1017. Sat0Y, Abe S, Mise K, Sasaki M, KamadaN, KoudaK, MusashiM, SaburiY, HorikoshiA, MinamiY, MiyakuniT,YokoyarnaY, IshiharaY,MiuraY (1987): Reciprocaltranslocationinvolving the short armsofchromosomes7 and 1 1, t(7p-;1 l p +),associatedwith myeloid leukemiawith maturation. Blood 7 0 1654-1 658.

130

ACUTE MYELOID LEUKEMIA

Sat0Y,SutoY, PietenpolJ, GolubTR,GillilandDG, Davis EM, Le BeauMM, RobertsJM,Vogelstein B, Rowley JD, BohlanderSK (1995): TEL and KIPZ define the smallestregion of deletionson 1 2 ~ 1 in 3 hematopoieticmalignancies.Blood 86: 1525-1 533. SatoY,BohlanderSK,KobayashiH,ReshmiS,SutoY,DavisEM,EspinosaRIII,HoopesR,Montgomery KT,KucherlapatiRS, Le BeauMM,RowleyJD ( 1997):Heterogeneityin the breakpointsin balanced rearrangements involvingband 1 2 ~ 1in 3 hematologicmalignanciesidentifiedby fluorescencein situ hybridization:TEL (ETv6) is involved in only one half. Blood9 0 4 8 8 M 9 3 . Scaglioni PP, Pandolfi PP (2007): The theory of APL revisited. Curr Top Microbiol Immunol 3 13%- 100. Schaich M, Schlenk RF,AI-Ali HK, E h n e rH, Ganser A, Heil G, Illmer T, Krahl R, KrauterJ, SauerlandC, BuchnerT, EhningerG (2007):Prognosisof acutemyeloid leukemiapatientsupto 60 years of age exhibitingtrisomy8 within a non-complexkaryotype:individualpatientdata-based meta-analysisof the GermanAcute Myeloid LeukemiaIntergroup.Haematologica92:763-770. ScheresJMJC,HustinxTWJ,HoldrinetRSG, GeraedtsJPM,HagemeijerA, van derBlij-PhilipsenM ( 1984): Translocation1;7 in dyshematopoiesis:possibly inducedwith a nonrandomgeographic distribution.Cancer Genet Cytogenel 12:283-294. ScheresJMJC,HustinxTWJ,GeraedtsJPM,LeeksmaCHW,MeltzerPS (1985): Translocation1 ;7 in hematologicdisorders:a brief review of 22 cases. Cancer Genet Cytogenet 18:207-213. SchlenkRF,BennerA, KrauterJ,BuchnerT, SauerlandC, EhningerG, SchaichM, MohrB,Niederwieser D, KrahlR, PasoldR, DohnerK, GanserA, D(ihnerH, Heil G (2004): Individualpatientdata-based meta-analysisofpatients aged I6to60yearswithcorebindingfactoracutemyeloidleukemia:asurvey of the GermanAcute Myeloid LeukemiaIntergroup.J Clin Oncol22:3741-3750. SchmidtHH, StrehlS, ThalerD, StrunkD, Sill H, LinkeschW, JagerU, SperrW, GreinixHT, Konig M, EmbergerW, HaasOA (2004): RT-PCRand FISH analysisof acutemyeloid leukemiawith t (8;16)(pl l;p13) and chimericMOZ and CBP transcripts:breakpointcluster region and clinical implications.Leukemia18:1115-1121. SchnittgerS, Kinkelin U, Schoch C, HeineckeA, Haase D, HaferlachT, BuchnerT, WormannB, HiddemannW, GriesingerF (2000): Screeningfor MLL tandemduplicationin 387 unselected patientswith AML identifya prognosticallyunfavorablesubsetof AML. LRukemia14796804. SchnittgerS, Schoch C, Dugas M, Kern W, Staib P, WuchterC, LafflerH, SauerlandCM, Serve H, BuchnerT, HaferlachT, HiddemannW (2002): Analysisof FLT3 lengthmutationsin 1003 patients withacutemyeloidleukemia:correlationtocytogenetics,FABsubtype,andprognosisintheAMLCG studyand usefulnessas a markerfor the detech'onof minimalresidualdisease. Blood 10059-66. SchnittgerS, KohlTM, HaferlachT. KernW, HiddeniannW, SpiekermannK, SchochC (2006): KZTD8 I6 mutationsin AMLf -ETO-positiveAML are associatedwith impairedevent-freeandoverall survival.Blood 107:179l-1799. Schoch C, Haase D, FonatschC, HaferlachT, LofflerH, SchlegelbergerB, Hossfeld D-K, BecherR, SauerlandMC, HeineckeA, WormannB, BuchnerT, HiddemannW (1997): The significanceof trisomy 8 in de novo acute myeloid leukaemia:the accompanyingchromosomeaberrations determinethe prognosis.Br J Haematol99:605-611. Schoch C, HaferlachT,Haase D, FonatschC, Loffler H, SchlegelbergerB, Staib P, SauerlandMC, HeineckeA, BuchnerT, HiddemannW (2001): Patientswithde novo acutemyeloidleukaemiaand complex karyotypeaberrationsshow a poor prognosisdespite intensivetreatment:a study of 90 patients.Br J Haematol 112: 1 18- 126. SchochC,HaferlachT, BurschS, GerstnerD, SchnittgerS, DugasM, KernW,LofflerH, HiddemannW (2002):Lossof geneticmaterialis morecommonthangainin acutemyeloidleukemiawithcomplex aberrantkaryotype:a detailedanalysisof 125 cases using conventionalchromosomeanalysisand fluorescencein situhybridizationincluding24-colorFTSH.GenesChromosomesCancer35:20-29. SchochC, SchnittgerS, KlausM, KernW, HiddemannW,HaferlachT (2003): AMLwith 11q23/MLL abnormalitiesas defined by the WHO classification:incidence, partnerchromosomes, FAB

REFERENCES

131

subtype, age distribution,and prognostic impact in an unselected series of 1897 cytogenetically analyzed AML cases. Blood 102:2395-2402. Schoch C, KernW, SchnittgerS, BiichnerT, HiddemannW. HaferlachT (2004): The influenceof age on prognosis of de novo acute myeloid leukemia differs according to cytogenetic subgroups. Haematologica 89:1082-1 090. Schoch C, KernW, KohlmannA, HiddemannW. SchnittgerS, HaferlachT (2005a): Acute myeloid leukemiawith a complexaberrantkaryotypeis a distinctbiological entitycharacterizedby genomic imbalancesand a specific gene expression profile. Genes ChromosomesCancer43:227-238. Schoch C, Kohlmann A, Dugas M, Kern W, Hiddemann W, Schnittger S, Haferlach T (2005b): Genomicgains andlosses influenceexpressionlevels of genes locatedwithin the affectedregions:a studyon acutemyeloid leukemiaswith trisomy8.1 I , or 13, monosomy 7, ordeletion 5q. Leukemia 1 9 1224-1228. SchoutenHC, van PuttenWLJ,HegemeijerA, BlijhamGH, SonneveldP, Willemze R, SlaterR, van de Lely J. VerdonckLF, LowenbergB ( 1991):The prognosticsignificanceof chromosomalfindingsin patients with acute myeloid leukemia in a study comparing the efficacy of autologous and allogeneic bone marrowtransplantation.Bone MarrowTransplant8:377-38 I . SchutteJ, OpalkaB, Becher R,BardenheuerW, SzymanskiS , Lux A, SeeberS (1993): Analysis of the p53 gene in patients with isochromosome 17q and Ph'-positive or -negative myeloid leukemia. LEuk Res 17:533-539. Scolnik MP, Palacios MF, Acevedo SH, CastumaMV, Lampa19, PalumboA, MoiraghiEB, Sasot AM. HubermanAB (1998): Promyelocytic blast crisis of chronic meylogenous leukaemiawith translocations(9;22) and (15; 17). Leuk Lymphoma3 I :231-236. Scott AA, Head DR, Kopecky KJ, AppelbaumFR, Theil KS, GreverMR, Chen I-M, WhittakerMH, GriffithBB, LichtJD, WaxmanS, WhalenMM, BankhurstAD, RichterLC, GroganTM, Willman CL (1994): HLA-DR-, CD33 +, CD56 f, CD16- rnyeloidnaturalkiller cell acute leukemia: a previously unrecognizedform of acute leukemiapotentiallymisdiagnosedas French-American-British acute myeloid leukemia-M3. Blood 84:244255. Secker-WalkerLM ( 1971 ): The chromosomesof bone-marrowcells of haematologicallynormalmen and women. Br J Haematol21:455461. Sccker-WalkerLM, Mehta A, Bain B, UKCCG(1995): Abnormalitiesof 3q2 I and 3q26 in myeloid malignancy: a United Kingdom CancerCytogenetic Groupstudy. Br J Haemat0191:49@-50 1. Secker-WalkerLM, StewartEL, Chan L, OCallaghanU, Chessells JM( I 985): The(4;I I ) translocation in acute leukaemiaof childhood;the importanceof additionalchromosomalaberrations.Br J Haematol61:101- I 1 1, Secker-WalkerLM, Moorman AV, Bain BJ, Mehta AB (1998): Secondary acute leukemia and myelodysplastic syndromewith 1 1q23 abnormalities.Leukemia 12840-844. SeedhouseC, Russell N (2007): Advances in the understandingof susceptibility to treatment-related acute myeloid leukaemia. Br J Haematol 137:513-529. Sekeres MA, Peterson 9, Dodge RK, Mayer RJ, Moore JO,Lee El, Kolitz J, Baer MR, SchifferCA, CarrollAJ, VardimanJW,Davey FR, BloomfieldCD. LarsonRA, StoneRM (2004): Differences in prognosticfactors and outcomes in African Americansand Whites with acute myeloid leukemia. Blood 103:4036-4042. Shago M, Bouman D, Kamel-Reid S, MindenM, Chun K (2004): Crypticinsertionof MLL gene into 9p22 leads to MLL-MLLT3 (AF9) fusion in a case of acute myelogenous leukemia. Genes ChromosomesCancer40:349-354. Qiu Q-Y, Zhu5, TangW, SunG-L, Yang K-Q, Chen Shen Z-X, Chen G-Q, Ni J-H, Li X-S, Xiong S-M, Y, Zhou L, FangZ-W, WangY-T, Ma J, ZhangP.ZhangT-D, ChenS-J, Chen Z, WangZ-Y (1997): Use of arsenic trioxide (AszO3) in the treatmentof acute promyelocytic leukemia (APL): 11. Clinical efficacy and pharmacokineticsin relapsed patients. Blood 89:3354-3360.

132

ACUTE MYELOID LEUKEMIA

ShigesadaK, van de Sluis B, Liu PP (2004): Mechanismof leukemogenesisby the inv(l6) chimeric gene CBFB/PEBPZB-MHYI1 . Oncogene 23:42974307. ShikamiM. Miwa H, Nishii K, TakahashiT, ShikuH. TsutaniH, OkaK, HamaguchiH, Kyo T,Tanaka K.KamadaN. KitaK (1 999): Myeloiddifferentiationantigenandcytokinereceptorexpressionon acute myelocytic leukaemiacells with t( I6;2 1 )(pl I ;q22): frequentexpression of CD56 and interleukin-2receptoralphachain. Br J Haematol 105:7 11-719. ShilatifardA, Lane WS, JacksonKW, ConawayRC, ConawayJW (1996): An RNA polymeraseI1 elongationfactorencoded by the humanELL gene. Science 271 :1873-1 876. ShimadaA, Taki T, TabuchiK, TawaA, HoribeK, TsuchidaM,HanadaR, TsukimotoI, HayashiY (2006): KITmutations,and not FLT3internaltandemduplication,are stronglyassociatedwith a poorprognosisin pediatricacutemyeloidleukemiawitht(8;21): a studyof the JapaneseChildhood AML CooperativeStudyGroup.Blood 107:1806-1809. ShimizuS, SuzukawaK, KoderaT, NagasawaT, Abe T, TaniwakiM,YagasakiF,TanakaH, Fujisawa S, JohanssonB, Ahlgren T, Yokota J, MorishitaK (2000): Identificationof breakpointcluster regionsat 1 p36.3 and 3q21 in hematologicmalignancieswith t( 1;3)(p36;q21).Genes Chromosomes Cancer 27:229-238. ShingDC, McMullanDJ, RobertsP, SmithK, ChinS-F, NicholsonJ,TillmanRM,RamaniP, Cullinane C, ColemanN (2003): FUS/ERG gene fusions in Ewing’stumors.Cancer Res 63:45684576. Silva FPG, Lind A, Brouwer-MandemaG, Valk PJM, Giphart-GasslerM (2007): Trisomy 13 correlateswith RUNXI mutationand increasedFLT3 expression in AML-MOpatients.Haematologica 92: 1123-1 126. SimmonsHM,OsethL, Nguyen P, O’LearyM, ConklinKF,HirschB (2002):Cytogeneticandmolecular heterogeneityof 7q36/12pl3 remangementsin childhoodAML. Leukemia 16:2408-2416. Slack JL, ArthurDC,LawrenceD, Mrozek K, Mayer RJ, Davey FR, TantravahiR, PettenatiMJ, Bigner S, Carroll AJ, Rao KW, Schiffer CA, Bloomfield CD (1997): Secondarycytogenetic changes in acute promyelocytic leukemia-prognostic importance in patients treated with chemotherapyalone and associationwith the intron 3 breakpointof the PML gene: a Cancer and LeukemiaGroupB study.J Clin Oncol15:178&1795. SlaterRM, von DrunenE, KroesWG, WeghuisDO, van den Berg E, Smit EM, van derDoes-vanden Berg A, van WeringE, Halen K, CarrollAJ, RaimondiSC, BeverlooHB (2001):t(7;12)(q36;p13) and t(7;12)(q32;p13)-translocations involving EW6 in children 18 monthsof age or younger with myeloid disorders.Leukemia 15:915-920. SlovakML,TraweekST. WillmanCL, Head DR, KopeckyKJ, MagenisRE,AppelbaumFR, Forman SJ (1995):Trisomy11 :an associationwithstedprogenitorcellimmunophenotype.Br J Haematol 90:266-273. SlovakML, KopeckyKJ, CassilethPA, HarringtonDH, Theil KS, MohamedA, PaiettaE, Willman CL, HeadDR, Rowe JM,FormanSJ,AppelbaumFR (2000):Karyotypicanalysispredictsoutcome of preremissionandpostremissiontherapyin adultacutemyeloidleukemia:a SouthwestOncology GrouplEastern CooperativeOncology Groupstudy. Blood 9640754083. Slovak ML, Bedell V, Popplewell L, Arber DA, Schoch C, Slater R (2002): 21q22 balanced chromosomeaberrationsin therapy-relatedhematopoieticdisorders:report from an international workshop.Genes Chromosomes Cancer 33:379-394. Slovak ML, GundackerH, Bloomfield CD, Dewald G, AppelbaumFR, LarsonRA, TallmanMS, BennettJM, StirewaltDL, MeshinchiS, WillmanCL, RavindranathY, Alonzo TA, CarrollAJ, RaimondiSC, HeeremaNA (2006): A retrospectivestudyof 69 patientswitht(6;9)(p23;q34)AML emphasizesthe need for a prospective,multicenterinitiativefor rare ‘poorprognosis’ myeloid malignancies.Leukemia 20: 1295-1297. Smith SM, Le Beau MM, Huo D, KarrisonT, Sobecks RM, AnastasiJ, VardimanJW, Rowley JD, Larson RA (2003): Clinical-cytogenetic associations in 306 patients with therapy-related

REFERENCES

133

myelodysplasia and myeloid leukemia: the University of Chicago series. Blood 102: 43-52. Smith AG, WorrillowLJ,Allan JM (2007): A common genetic variantin XPD associates with risk of 5q- and 7q-deleted acute myeloid leukemia. Blood 109: 1233-1 236. SnaddonJ, Neat M, FitzgibbonJ, SmithML, RohatinerAZ, ListerTA, Amess JA (2002):Mutationsin the runthomology domain of CBFa2 in myeloid malignancies with acquiredtrisomy 21. Cancer Genet Cytogenet 136:15 1-152. So CW. Caldas C, Liu M-M, Chen S-J, HuangQ-H, Gu L-J, Sham MH, WiedemannLM, Chan LC ( 1 997): EEN encodes for a member of a new family of proteins containing an Src homology 3 domainand is the thirdgene locatedon chromosome 19pJ 3 that fuses to MLL in humanleukemia. Proc Nut1 Acud Sci USA 94:2563-2568. SoekarmanD, von Lindem M, van der Plas DC,Selleri L, BartramCRI, MartiatP, Culligan D, Padua RA, Hasper-VoogtKP, HagemeijerA, GrosveldG ( 1992):Dek-cunrearrangementin translocation (6;9)(p23;q34).Leukemia 6:489-494. Soignet SL, MaslakP, WangZ-G, JhanwarS, CallejaE, DardashtiLJ,CorsoD, DeBlasio A, Gabrilove J, ScheinbergDA, PandolfiPP, WarrellRPJr( I 998): Completeremissionaftertreatmentof acute promyelocytic leukemia with arsenic trioxide. N Engl J Med 339:1341-1 348. Soni M, BrodyJ, Allen SL. SchulmanP, KolitzJ, Rai K, BroomeJD, KoduruPRK (1996):Clinicaland morphological features of cases of trisomy 13 in acute non-lymphocytic leukemia. Leukemia 10619-623. Sorensen PHB, Chen C-S, Smith FO, ArthurDC, Domer PH, Bemstein [D, KorsmeyerSJ, Hammond GD, Kersey JH (1 994): Molecular rearrangementsof the M U gene are present in most cases of infant acute myeloid leukemia and are strongly correlatedwith monocytic or myelomonocytic phenotypes. J Clin lnvest 93:429-437. Soupir CP. Vergilio J-A, Dal Cin P, Muzikansky A, KantarjianH, Jones D, HasserjianRP (2007): Philadelphia chromosome-positive acute myeloid leukemia: a rare aggressive leukemia with clinicopathologicfeaturesdistinct from chtonic myeloid leukemia in myeloid blast crisis. Am J Clin Pathol 127:642-650. SreekantaiahC , Baer MR, PreislcrHD, SandbergAA ( 1989): lnvolvementof bands9q2 1-q22 in five cases of acute nonlymphocyticleukemia. Cancer Genet Cytogenet 39:55-64. Steensma DP, Dewald GW, Hodnefield JM, Tefferi A, Hanson CA (2003): Clonal cytogenetic abnormalitiesin bone marrow specimens without clear morphologic evidence of dysplasia: a form fruste of myelodysplasia? Leuk Res 27:235-242. SterkersU, PreudhommeC, Lai J-L, Demory J-L. CaulierM-T, WattelE, Bordessoule D, BautersF, Fenaux P (1998): Acute myeloid leukemia and myelodysplastic syndromesfollowing essential thrombocythemiatreated with hydroxyurea:high proportionof cases with 17p deletion. Blood 91 :616-622. Steudel C, Wermke M, Schaich M, SchiikeJ U, Illmer T, Ehninger G, Thiede C (2003): Comparativeanalysis of MLL partial tandem duplication and FLT3 internaltandem duplication mutations in 956 adult patients with acute myeloid leukemia. Genes Chromosomes Cancer 37~237-251. Storlazzi CT, FioretosT, SuraceC, Lonoce A, MastrorilliA. StrombeckB, D'AddabboP, lacovelli F, Minervini C, Aventin A, Dastugue N, Fonatsch C, HagemeijerA, JotterandM, MuhlematterD, Lafage-Pochitaloff M, Nguyen-Khac F, Schtxh C, Slovak ML, Smith A, Sole F, Van Roy N, Johansson B, Rocchi M (2006): MYC-containingdouble minutes in hematologic malignancies: evidence in favor of the episome model and exclusion of MYC as the targetgene. Hum Mol Genet I5:933-942. StrehlS , BorkhardtA, SlanyR, FuchsUE, Konig M, HaasOA (2003):The humanL A P I gene is fused to MLL in an acute myeloid leukemia with t( I ;17)(q23;q21). Oncogene 22: 157-1 60.

134

ACUTE MYELOID LEUKEMIA

Strehl S, Konig M, Meyer C, SchneiderB, HarbottJ, Jager U, von Bergh ARM, LoncarevicIF, JarosovaM, SchmidtHH, MooreSDP, MarschalekR. HaasOA (2006): Moleculardissectionof t (1 1 ;17) in acute myeloid leukemiareveals a varietyof gene fusions with heterogeneousfusion transcriptsand multiplesplice variants.Genes Chromosomes Cancer 45: 1041-1049. StreubelB, SauerlandC, Heil G, FreundM, BartelsH, LengfelderE, WandtH, LudwigW-D, Nowotny H, Baldus M, Grothaus-PinkeB, Buchner T. Fonatsch C (1998): Correlationof cytogenetic, molecularcytogenetic,andclinical findingsin 59 patientswith ANLL or MDS andabnormalities of the short arm of chromosome12. Br J Haematol 100521-533. StreubelB , Valent P, JagerU, EdelhauserM, WandtH, WagnerT, BiichnerT, LechnerK, FonatschC (2000): Amplificationof the MLL gene on doubleminutes,a homogeneouslystainingregion,and ring chromosomesin five patientswith acute myeloid leukemiaor myelodysplasticsyndrome. Genes Chromosomes Cancer 27:380-386. StubbsMC, Kim YM, KrivtsovAV, WrightRD, FengZ, AgarwalJ, KungAL, ArmstrongSA (2008): MLL-AF9 and FLT3 cooperationin acute rnyelogenousleukemia:developmentof a model for rapidtherapeuticassessment.Leukemia 22:66-77. Suela J, Alvarez S , CifuentesF, LargoC, FerreiraBI, Blesa D, ArdanazM, GarciaR, MarquezJA, OderoMD, CalasanzMJ,CigudosaJC(2007): DNA profilinganalysisof 100 consecutivede novo acutemyeloid leukemiacases revealspatternsof genornicinstabilitythataffectall cytogeneticrisk groups.Leukemia 2 I :1224-123 1. SuenagaM, Sanada1, TsukamotoA, Sat0 M, Kawano F, Shido T, Miura K, TominagaR (1993): Trisomy 4 in a case of acute myelogenousleukemiaaccompaniedby subcutaneoussoft tissue tumors.Reportof a case and review of the literature.Cancer Genet Cytogenet 71:71-75. SuzukawaK, ParganasE, GajjarA, Abe T, TakahashiS, Tani K, AsanoS, Asou H, KamadaN, Yokota J, MorishitaK, Ihle JN (1994): Identificationof a breakpointclusterregion 3' of the ribophorinI gene at 3q21 associatedwith the transcriptional activationof the EVll gene in acutemyelogenous leukemiaswith inv(3)(q21q26).Blood 84:2681-2688. SwansburyGJ, Feary SW, Clink H, Lawler SD'(1985): Cytogenetics of acute promyelocytic leukaemia:incidenceoft( 15;17) at the Royal MarsdenHospital,London.Leuk Res 9:271-278. SwansburyGJ, SlaterR, Bain BJ, MoormanAV, Secker-WalkerLM (1998): Hematologicalmalignancies with t(9;l l)(p21-22;q23)-a laboratoryand clinical study of 125 cases. Leukemia 12:792-800. Sweet DL, GolombHM,Rowley JD, VardimanJM( 1979):Acutemyelogenousleukemiaandthrombocythemiaassociatedwith an abnormalityof chromosomeno. 3. Cancer Genet Cytogenet 1:33-37. SweetserDA, PeniketAJ, HaalandC, BlombergAA, ZhangY, ZaidiST,DayyaniF,ZhaoZ, Heerema NA, BoultwoodJ, Dewald GW, PaiettaE, SlovakML, WillmanCL, WainscoatIS, BernsteinID, Daly SB (2005): Delineation of the minimal commonly deleted segment and identificationof candidate tumor-suppressorgenes in del(9q) acute myeloid leukemia. Genes Chromosomes Cancer M279-291. SwirskyDM, Li YS, MatthewsJG, FlemansRJ, Rees JKH,HayhoeFGJ (1984): 8;21 translocationin acute granulocyticleukaemia:cytological, cytochemicaland clinical features.Br J Huematol 56~199-213. TakatsukiH, Yufu Y, TachikawaY, Uike N (2002): Monitoringminimal residualdisease in patients with MU-AF6 fusion transcript-positiveacute myeloid leukemia following allogeneic bone marrowtransplantation. Int J Hematol75:29&301. TaketaniT, Taki T, Ono R, KobayashiY, Ida K, HayashiY (2002): The chromosometranslocation t(7;l l)(p15;p15) in acute myeloid leukemiaresults in fusion of the NUP98 gene with a HOX4 clustergene, HOXA13, but not HOXA9. Genes Chromosomes Cancer 3 4 4 3 7 4 3 . TaketanjT, TakiT, TakitaJ, TsuchidaM, HanadaR, HongoT, KanekoT, ManabeA, IdaK, HayashiY (2003):AMLI/RUhW mutationsare infrequent,butrelatedto AML-MO,acquiredtrisomy21, and

REFERENCES

135

leukemic transformationin pediatrichematologicmalignancies.Genes Chromosomes Cancer 38:1-7. Taki T, Ohnishi H, ShinoharaK, Sako M, Bessho F, YanagisawaM, HayashiY (1999): AFI7q25, a putativeseptinfamilygene, fusestheMLL gene in acutemyeloidleukemiawitht( I I ;I7)(q23;q25). Cancer Res 59:426 14265. Taki T,AkiyamaM, Saito S, On0 R, TaniwakiM, Kato Y, Yuza Y, Eto Y, Hayashi Y (2005): The MYOIF, unconventionalmyosin type IF, gene is fused to MLL in infant acute monocytic leukemia with a complex translocationinvolving chromosomes7, 1 I , 19 and 22. Oncogene 2 4 5 191-5 197. Tallman MS, HakimianD, Shaw JM, Lissner GS, Russell EJ, VariakojisD (1993): Granulocytic sarcoma is associated with the 8;21 translocationin acute myeloid leukemia. J Clin Oncol 1 1 :690697. TallmanMS, Dewald GW, GandhamS, Logan BR, KeatingA, LazarusHM. Litzow MR, Mehta J, PedersenT, Perez WS, Rowe JM,Wetzler M, Weisdorf DJ (2007): Impactof cytogeneticson for acute myeloid outcomeof matchedunrelateddonorhematopoieticstem cell transplantation leukemiain first or second complete remission.Blood 110409-417. TanabeS, Zeleznik-Le NJ, KobayashiH, Vignon C, Espinosa R 111, LeBeau MM, ThirmanMJ, Rowley JD (1996): Analysisof the t ( 6 1 l)(q27;q23)in leukemiashowsa consistentbreakpointin AF6 in threepatientsand in the ML-2 cell line. Genes Chromosomes Cancer 15:2Oti216. ThiedeC, SteudelC, MohrB, SchaichM,SchlikelU, PlatzbeckerU,WermkeM, BomhauserM, Ritter M, NeubauerA, EhningerG, Illmer T (2002): Analysis of FLT3-activatingmutationsin 979 patientswith acute myelogenousleukemia:associationwith FAB subtypesand identificationof subgroupswith poor prognosis.Blood 99:4326-4335. ThirmanMJ,Gill HJ,BumettRC, MbangkolloD, McCabeNR,KobayashiH, Ziemin-vander Poel S, KanekoY, MorganR, SandbergAA, ChagantiRSK, LarsonRA, Le Beau MM, Diaz MO, Rowley JD (1993): Rearrangementof the MLL gene in acute lymphoblasticand acutemyeloid leukemias with 1 1q23 chromosomaltranslocations.N Engl J Med 32999-9 14. ThirmanMJ, LevitanDA, KobayashiH, Simon MC, Rowley JD (1994): Cloningof ELL, a gene that fuses to M U in a t(11;19)(q23;pl3.1)in acute myeloid leukemia. Proc Nut1 Acad Sci USA 91:12110-12114. TienH-F,WangC-H,ChuangS-M,Lee F-Y, Liu M-C,ChenYC, Shen M-C, Lin D-T, Lin K-H, Lin KS, Liu C-H ( 1992): Characterizationof Philadelphia-chromosome-positive acute leukemia by clinical, immunocytochemical,and gene analysis.Leukemia 6:9O7-9 14. Tien H-F. WangC-H, Lin M-T, Lee F-Y, Liu M-C,ChuangS-M, ChenY-C, ShenM-C, Lin K-H, Lin genotype,clinicalfeatures, D-T ( 1995):Correlationof cytogeneticresultswith immunophenotype, and ras mutationin acute myeloid leukemia.A studyof 235 Chinesepatientsin Taiwan.Cancer Genet Cytogenet 84:60-68. TkachukDC. Kohler S, ClearyML (1992): Involvementof a homolog of Drosophilatrithoraxby II q23 chromosomaltranslocationsin acute leukemias. Cell 7 1 :691-700. TokitaK, Maki K, Mitani K (2007): RUNXIEV11, which blocks myeloid differentiation,inhibits CCAAT-enhancerbindingproteinalpha function. Cancer Sci 98:1752- 1757. Tosi S, Giudici G, Mosna G, HarbottJ, Specchia G, Grosveld G, PriviteraE, Kearney L, Biondi A, Cazzaniga G (1998): Identification of new partner chromosomes involved in fusions with the ETV6 (TEL) gene in hematologic malignancies. Genes Chromosomes Cancer 21 :223-229. Tosi S, SchererSW, GiudiciG, CzepulkowskiB, Biondi A, KeameyL ( 1 999): Delineationof multiple deleted regions in 7q in myeloid disorders.Genes Chromosomes Cancer 25:384-392. Tosi S , Harbott J, Teigler-Schlegel A, Haas OA, Pirc-DanoewinataH, Harrison CJ, Biondi A, Cazzaniga G, Kempski H, Scherer SW, Kearney L (2000): t(7;12)(q36;p13), a new

136

ACUTE MYELOID LEUKEMIA

recurrenttranslocationinvolving E m 6 in infant leukemia. Genes Chromosomes Cancer 29~325-332. Tosi S, HughesJ, SchererSW, NakabayashiK. HarbottJ, HaasOA, CazzanigaG , BiondiA, Kempski H, KeameyL (2003): Heterogeneityof the 7q36 breakpointsin the t(7;12)involvingETV6 in infant leukemia.Genes Chromosomes Cancer 38: 191-200. Trobaugh-Lotrario AD, KletzelM, QuinonesRR, McGavranL, ProytchevaMA, HungerSP, Malcolm J, Schissel D, Hild E, Giller RH (2005): Monosomy 7 associatedwith pediatricacute myeloid leukemia(AML) and myelodysplasticsyndrome(MDS): successful managementby allogeneic hematopoieticstem cell transplant(HSCT).Bone Marrow Transplant 35:143-1 49. TrubiaM, Albano F, Cavazzini F, CambrinGR, Quarta G, FabbianoF, Ciambelli F, Magro D, HemandemJM,ManciniM, DiverioD, PelicciPG,Coco FL,MecucciC, SpecchiaG, Rocchi M, Liso V, CastoldiG, CuneoA (2006): Characterization of a recurrenttranslocationt(2;3)(p15-22; q26) occurringin acute myeloid leukaemia.Leukemia 20:48-54. Tse W, Zhu W,ChenHS, CohenA ( I 995): A novel gene, AFlq, fusedto M U in t( 1 ;1 1 )(q21;q23),is specifically expressedin leukemic and immaturehematopoieticcells. Blood 85:650-656. Tse W, MeshinchiS, Alonzo TA, StirewaltDL, GerbingRB, WoodsWG, AppelbaumFX,RadichJ p (2004): Elevatedexpressionof theA F l q gene, an MLLfusion partner,is an independentadverse prognosticfactor in pediatricacute myeloid leukemia.Blood 104:3058-3063. Tyyb&inojaA, ElonenE, PiippoK, PorkkaK, KnuutilaS (2007):Oligonucleotidearray-CGHreveals crypticgene copy numberalterationsin karyotypically normalacutemyeloidleukemia.Leukemia 21571-574. UKCCG (United KingdomCancerCytogeneticsGroup)(1992a): Primary,single, autosomd trisomies associatedwith haematologicaldisorders.Leuk Res 16:841-851. UKCCG (United KingdomCancerCytogeneticsGroup)( I 992b): Translocationsinvolving 12p in acutemyeloid leukemia:associationwith priormyelodysplasiaandexposureto mutagenicagents. Genes Chromosomes Cancer 5:252-254. UKCCG(United KingdomCancerCytogeneticsGroup)(1 992c): Loss of the Y chromosomefrom normaland neoplasticbone marrows.Genes Chromosomes Cancer 5:83-88. Valk PJM,VerhaakRGW,BeijenMA, ErpelinckCAJ.Barjestehvan Waalwijkvan Doom-Khosrovani S, Boer JM, Beverloo HB, MoorhouseMJ, van der Spek PJ, LowenbergB, Delwel R (2004): Prognosticallyuseful gene-expression profiles in acute myeloid leukemia. N Engl J Med 350 1617-1 628. Van Den Berghe H, David G, MichauxJ-L, Sokal G, VerwilghenR (1976): 5q- acute myelogenous leukemia.Blood 4k624-625. Van Den Berghe H, LouwagieA, Broeckaert-VanOrshovenA, David G, VerwilghenR, MichauxJL, Sokal G (1979): Chromosomeabnormalitiesin acute promyelocyticleukemia (APL). Cancer 431558-562. van derReijdenBA, Lombard0M, DauwerseHG, Giles RH, MuhlematterD, JotterandBellomoM, Wessels HW,BeverstockGC, van OmmenG-JB,HagemeijerA, BreuningMH (1995): RT-PCR diagnosisof patientswith acutenonlymphocyticleukemiaandinv(I6)(p13q22)andidentification of new alternativesplicing in CBFB-MYHI1 transcripts.Blood 86:277-282. van der StraatenHM, van Biezen A, Brand R, SchattenbergAVMB, Egeler RM, Barge RM, CornelissenJJ, Schouten HC, OssenkoppeleGJ, Verdonck LF (2005): Allogeneic stem cell for patientswith acutemyeloid leukemiaor myelodysplasticsyndromewho have transplantation chromosome5 and/or7 abnormalities.Huematologica 90: 1339-1345. Van LimbergenH, PoppeB, MichauxL, HerensC, BrownJ, Noens L, BernemanZ, De Bock R, De PaepeA, SpelemanF (2002): identificationof cytogeneticsubclassesandrecurringchromosomal aberrationsin A M Land MDS with complex karyotypesusing M-FISH. Genes Chromosomes Cancer 33:60-72.

REFERENCES

137

van Zutven UCM, Onen E, Velthuizen SCJM, van Drunen E, von Bergh ARM, van den HeuvelEibrinkMM, VeroneseA, Mecucci C, Negrini M, de GreefGE, Beverloo HB (2006):Identification of NUP98 abnormalitiesin acute leukemia: JARIDIA ( 1 2 ~ 1 3as ) a new partnergene. Genes Chromosomes Cancer 45437-446. Velloso ERP, Mecucci C, Michaux L, van OrshovenA, Stul M, Boogaerts M, Body A, CassimanJ-J, van den Berghe H (1996):Translocationt(8;16)(pl1;PI 3 ) in acute non-lymphocytic leukemia: reporton two new cases and review of the literature.Leuk Lymphoma 21:137-142. Vitoux D, Nasr R, de The H (2007):Acute promyelocytic leukemia:new issues on pathogenesisand treatmentresponse. Int J Biochem Cell Biol39:1063-1070. von Bergh ARM, van Drunen E, van WeringER, van Zutven LJCM, HainmannI, LonnerholmG, MeijerinkJP, Pieters R, Beverloo HB (2006):High incidence of t(7;12)(q36;pl3)in infant AML but not in infant ALL, with a dismal outcome and ectopic expression of HLxB9. Genes Chromosomes Cancer 4573 1-739. von Lindern M, Poustka A, Lerach H, Grosveld G (1990): The (6;9)chromosome translocation, associated with a specific subtypeof acute nonlymphocyticleukemia, leads to aberranttranscription of a target gene on 9q34. Mol Cell Biolt0:4016-4026. von Lindern M, Fomerod M, van Baal S, Jaegle M, de Wit T, Buijs A, Grosveld G (1992):The translocation(6;9),associated with a specific subtype of acute myeloid leukemia, results in the fusion of two genes, a'ek and can, and the expression of a chimeric, leukemia-specific a'ek-can mRNA. Mol Cell Biol 12:1687-1697. VoutsadakisIA.MaillardN (2003):Acute myelogenous leukemiawith the t(3;12)(q26;pl3)translocation: case reportand review of the literature.Am JHematol72:135-137. Wang PW, EisenbartJD, Espinosa R 111, Davis EM, LarsonRA, Le Beau MM (2000):Refinementof the smallest commonly deleted segment of chromosome 20 in malignant myeloid diseases and development of a PAC-basedphysical and transcriptionmap. Genomics 67:28-39. Wang L, Ogawa S, HangaishiA, Qiao Y,Hosoya N, Nanya Y, Ohyashiki K, Mimguchi H. Hirai H (2003):Molecularcharacterizationof the recurrentunbalancedtranslocationder(1;7)(qlO;pIO). Blood 10212597-2604. WarnerJK, WangJCY, TakenakaK, Doulatov S, McKenzieJL, HarringtonL, Dick JE(2005):Direct evidence for cooperating genetic events in the leukemic transformationof normal human hematopoieticcells. Leukemia 19:1794- 1805. WarrellRPJr,FrankelSR, MillerWH Jr,ScheinbergDA, Itri LM. HittelmanWN, Vyas R, AndreeffM, TafuriA, JakubowskiA, GabriloveJ, GordonMS, DmitrovskyE (1 99 1 ): Differentiationtherapyof acutepromyelocyticleukemiawith tretinoin(all-trans-retinoicacid). N EnglJMed324: 1385-1393. WeberE, Nowotny H, Haas OA, KasparuH, Grois N, Lutz D ( 1990):Trisomy4: a specific karyotype anomaly in primaryand secondary acute myeloid leukemia. Leukemiu 4:219-221. Weh HJ, KabischH, LandbeckG, Hossfeld DK (1986):Translocation(9;Il)(p21 ;q23) in achild with acute monoblasticleukemiafollowing 2 1/2 years aftersuccessful chemotherapyfor neuroblastoma. J Clin Oncol4:1518-1520. Weh HJ,KuseR, Hossfeld DK (1 990):Acute nonlymphocyticleukemia(ANLL)with isochromosome i( 17q) as the sole chromosomalanomaly: a distinct entity? EurJ Haematol44312-314. WeinfeldA, WestinJ,Ridell B, Swolin B (1977):PolycythemiaVeraterminatingin acuteleukaemia.A clinical, cytogenetic and morphologicstudy in 8 patients treatedwith alkylating agents. Scand J Haematol 19:255-272. Weisser M, Haferlach C, Haferlach T,SchnittgerS (2007):Advanced age and high initial WBC influence the outcome of inv(3)(q21q26)/t(3;3)(q21;q26) positive AML. LRuk Lymphoma 48:2145-2151. Welbom J (2004):Constitutional chromosome aberrationsas pathogenetic events in hematologic malignancies. Cancer Genet Cytogenet 149 137-153.

138

ACUTE MYELOID LEUKEMIA

WelbornJL, Lewis JP, JenksH, Walling P (1987): Diagnostic and prognostic significanceof t( 1;3) (p36;q21) in the disordersof hematopoiesis. Cancer Genet Cytogenet 28:277-285. Wells RA, CatzavelosC, Kamel-Reid S ( 1997): Fusion of retinoicacid receptora to NuMA, the nuclearmitoticapparatusprotein,by a varianttranslocationin acutepromyelocyticleukaemia.Nut Genet 17:109-113. WestbrookCA, Le Beau MM, Diaz MO, GroffenJ ( I 985): Chromosomallocalizationand characterization of c-abl in the t(6;9) of acute nonlymphocytic leukemia. Proc Natl Acad Sci USA 828742-8746. WiemelsJL,Xiao Z, BufflerPA, MaiaAT, Ma X, Dicks BM, SmithMT,ZhangL, FeusnerJ, Wiencke J, Pritchard-JonesK, Kempski H, Greaves M (2002): In utero origin of t(8;21) AMLI-ETO translocationsin childhood acute myeloid leukemia.Blood 99:380 1-3805. WiernikPH, DutcherJP,PaiettaE, HittelmanWN, Vyas R, StrackM, CastaigneS,Degos L, Gallagher RE (199 1): Treatmentof promyelocytic blast crisis of chronicmyelogenous leukemia with all trans-retinoicacid. Leukemia 5:504-509. Wieser R, Volz A, VinatzerU, GardinerK, JagerU, MitterbauerM, Ziegler A, FonatschC (2000): TranscriptionfactorGATA-2 is located near 3q21 breakpointsin myeloid leukemia. Biochem Biophys Res Commun 273:239-245. Wiktor A, Rybicki BA, Piao ZS, Shurafa M, Barthel B, Maeda K, Van Dyke DL (2000): Clinicalsignificanceof Y chromosomeloss in hematologicdisease.Genes ChromosomesCancer 27:11-16. WildaM, PerezAV, BruchJ, WoessmannW, MetzlerM, Fuchs U, BorkhardtA (2005): Use of M U GRAF fusionmRNAformeasurementof minimalresidualdiseaseduringchemotherapyin aninfant with acutemonoblasticleukemia(AML-M5). Genes Chromosomes Cancer 43:424426. Wilmoth D, Feder M, Finan J, Nowell P (1985): Preleukemiaand leukemia with 12p- and 19q+ chromosomealterationsfollowing alkerantherapy.Cancer Genet Cytogenet1 5:95-98. WlodarskaI, La StarzaR, Baens M, DierlammJ, UyttebroeckA, SelleslagD, FrancineA, MecucciC, Hagemeijer A, Van den Berghe H, Marynen P (1998): Fluorescence in situ hybridization characterization of new translocationsinvolving TEL ( E W 6 ) in a wide spectrumof hematologic malignancies. Blood 91 :1399-1406. WolmanSR, GundackerH, AppelbaumFR, Slovak ML (2002): Impactof trisomy8 ( +8) on clinical presentation,treatmentresponse, and survivalin acutemyeloid leukemia:a SouthwestOncology Groupstudy. Blood 10029-35. Wong KF, Kwong YL ( I 999): Trisomy22 in acutemyeloid leukemia:a markerfor myeloid leukemia with monocytic features and cytogenetically cryptic inversion 16. Cancer Genet Cytogenet 109: 131-133. Wu Y, Slovak ML, SnyderDS, ArberDA (2006): Coexistenceof inversion 16 and the Philadelphia chromosomein acute andchronicmyeloid leukemias:reportof six cases and review of literature. Am J Clin Pathol 125:260-266. Xu L, ZhaoW-L, Xiong S-M, Su X-Y, ZhaoM, WangC, Gao Y-R,Niu C, Cao Q, Gu B-W, ZhuY-M, Gu J, Hu .I, Yan H, ShenZ-X, ChenZ, ChenS-J(2001): Molecularcytogeneticcharacterizationand clinical relevance of additional,complex and/or variantchromosome abnormalitiesin acute promyelocytic leukemia.Leukemia 15:1359-1 368. YamadaY,FurusawaS (1 976): Preferentialinvolvementof chromosomesno. 8 and no. 21 in acute leukemia and preleukemia.Blood 47:679-686. YamamotoK, Nagata K, HamaguchiH (2002): A new case of CD7-positive acute myeloblastic leukemiawith trisomy21 as a sole acquiredabnormality.Cancer Genet Cytogenet 133:183-184. Yao E-I, SadamoriN, NakamuraH, SasagawaI, ItoyamaT, IchimaruM, Tagawa M, NakamuraI, Kamei T (1988): Translocation t( 16;21) in acute nonlymphocytic leukemia with abnormal eosinophils. Cancer Genet Cytogenet 3622 1-223.

REFERENCES

139

Yoneda-KatoN, Look AT, KirsteinMN, ValentineMB, Raimondi SC, Cohen KJ, CarrollAJ, Moms SW ( 1 996): The t(3;5)(q25.1;q34) of myelodysplastic syndrome and acute myeloid leukemia producesa novel fusion gene. NPM-MLFI. Oncogene 12:265-275. Yuan Y, Zhou L, Miyamoto T, lwasaki H,HarakawaN, HetheringtonCJ, Burel SA, Lagasse E, Weissman IL, Akashi K, Zhang DE (2001): AMLl-ETOexpression is directly involved in the development of acute myeloid leukemia in the presence of additionalmutations.Proc Nut1 Acad Sci USA 98:10398-10403. Yunis JJ (1984): Recurrentchromosomaldefects arefound in most patients with acute nonlymphocytic leukemia. CancerGenet Cytogenet 1 1 :125-1 37. Yunis JJ, Bloomfield CD, Ensrud K (1981): All patients with acute nonlymphocytic leukemia may have a chromosomaldefect. N Engl J Med 305:135-1 39. ZaccariaA, Rosti G, TestoniN (1982): Reciprocaltranslocation(1 iq +;17q-) in a patientwith acute monoblastic leukemia. Nouv Rev F r Hematol24:389-390. Zaccaria A, Rosti G , Testoni N, TuraS ( 1985): Chromosome12 rearrangementwith breakageat the pl I level in hematologic disorders:reportof four cases. CancerGenet Cytogenet 15309-314. Zatkova A, Ullmann R, Rouillard JM, Lamb BJ, Kuick R, Hanash SM, SchnittgerS. Schoch C. Fonatsch C, Wimmer K (2004): Distinct sequences on 1 lq13.5 and 1 lq23-24 are frequently coamplified with MLL in complexly organized 1 Iq amplicons in AML/MDS patients. Genes ChromosomesCancer 39:263-276. Ziemin-vanderPoel S, McCabeNR, Gill HJ,EspinosaRIII, PatelY,HardenA, RubinelliP, SmithSD, Le Beau MM, Rowley JD, Diaz MO (1 99 I): Identificationof a gene, M U , thatspansthe breakpointin 1 lq23 translocationsassociatedwith humanleukemias.ProcNatl AcadSci USA 88: 10735-10739. Zou J, Ichikawa H, BlackburnML, Hu H-M,Zielinska-KwiatkowskaA, Mei Q, Roth GJ, Chansky HA, Yang L (2005): The oncogenic TLS-ERGfusion proteinexerts different effects in hematopoietic cells and fibroblasts.Mol Cell Biol25:6235-6246.

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CHAPTER6

Myelodysplastic Syndromes

The myelodysplasticsyndromes(MDS) are a heterogeneousgroupof clonal bone marrow disorderscharacterizedby the presenceof dysplasticmaturationof hematopoieticcells coupled with one or more peripheralcytopeniasand a propensityto progressto an acute leukemia(Vardiman,2003; CazzolaandMalcovati,2005). The incidenceof MDS increases with age (over 85%of patientsare morethan60 years of age) and MDS affects more men than women (4.5 versus 2.3 per 100,000) (Ma et al., 2007). While exposureto tobacco, solvents, and farmingchemicals areassociatedwith MDS, most cases occur withoutany apparentcause (Strom et al., 2008). Approximately 10-15% of MDS follow treatment (therapy-related MDS;t-MDS)withchemotherapyandradiationforboth neoplasticas well as benign disorders(Godley and Larson,2002). Although bone marrowdysplasiais the cardinalfeatureof MDS, therearea numberof otherconditionsthatmay presenta similar histopathologicpicture. Nutritionaldeficienciesof, for example, vitamin B l2 and folate, toxins, infections,and congenitalconditionsrepresentdifferentialdiagnoses and must be excluded. In contrast, documenting the clonality of the abnormalcells supports the diagnosis (Jaffe et al., 2001; Bowen et al., 2003). The currentdiagnostic entities of MDS are establishedusing WorldHealthOrganization (WHO) criteria.This classification is based on bone marrowhistology, blast count, and cytogenetic findings (Table 6.1). In the previous French-American-British (FAB) classification (Bennett et al., 1982), chronic myelomonocytic leukemia (CMML) was also consideredto be a subtypeof MDS; this entity is now consideredto be an overlap disorderwith a dysplastic subtype possessing many of the clinical characteristicsof the otherMDS. The naturalhistoryof MDS, includingthe risk of leukemictransformation,is significantly worsened by an increasing marrowblast count. In patients with low blast counts, the presence of dysplasia in a single cell line, most commonly erythroid,is distinguishedfromcases with multilineagedysplasia,which have a worse prognosis.The presence of ringed sideroblasts is recognized when 215% of erythroidprecursorsare ringed sideroblasts. The cytogenetic evaluation of a bone marrowsample from patients with MDS has become an integralpartof clinicalcare.Not only does this analysisconfirmthe diagnosis,it is invaluable in assessing the prognosis, the risk for progression to an acute myeloid

Cuncer Cytogenetics. Third Edition, edited by Sverre Heim and Felix Miteelman Copyright 0 2009 John Wiley & Sons, Inc.

141

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MYELODYSPIASTIC SYNDROMES

TABLE 6.1 World Health Organization MDS Classification System

Disease Refractoryanemia (RA) RA with ringed sideroblasts 5q- syndrome

Refractorycytopenia with multilineagedysplasia (RCMD) RCMD with ringed sideroblasts Refractoryanemiawith excess of blasts-1 Refractoryanemiawith excess of blasts-2 Myelodysplasticsyndromeunclassified Chronicmyelomonocyticleukemia (CMML)-nonproliferative type

Marrow Blasts < 5% <5 % < 5% < 5%

Cytogenetic Clinical Presentation Abnormalities Anemia 25% Anemia, >_ 15%ringed 10% sideroblastsin erythroid precursors Anemia, normalplatelets 100% Bicytopeniaor pancytopenia 50%

5-9%

Bicytopeniaor pancytopenia, > 15%ringed sideroblasts Cytopenias +/- blasts ( < 5%)

50-7095

1&20%

Cytopenias,blasts present

50-70%

< 5%

Neutropeniaor thrombocytopenia Monocytosis (> IOOO/pL), total leukocytesI 13,OOO/pL

50%

< 5%

< 20%

50%

2550%

leukemia(AML),andthe likely survival.On a morefundamentallevel, cytogeneticanalysis has been instrumentalin establishingthe clonality of these syndromesas well as providing hints about their pathobiology.This chapterwill review the most frequentlyencountered abnormalitiesexploring their clinical and genetic features.

DIAGNOSIS The diagnosis of all hematological malignancies,includingMDS, begins with the appropriate clinical evaluation combined with expert pathological and genetic analysis. An accuratediagnosis can be crucial in managementdecisions. In cases of MDS with multilineage dysplasia and an elevated blast count accompaniedby typical laboratoryfindings, the diagnosis of MDS is relatively straightforward.Given the varied pathological and clinical pictureof MDS, however, more sophisticatedtesting may be useful in establishing the diagnosis. The most widely availableand standardizedtechniquefor identifyingclonalityin MDS is classical chromosomebandinganalysis.In fact, the WHO(Jaffeet a]., 2001) has included recurringcytogenetic abnormalitiesin the classificationof several subtypesof MDS with distinctclinical presentationsand naturalhistoriesas discussed subsequently.The analysis of mutatedoncogenes or tumorsuppressorgenes has been used to confirmthe clonal nature of MDS and to provideadditionalprognosticinformation(Weimaret al., 1994). Aberrantin vitro growthpatternsof stem cells can be characteristicof MDS (Spitzeret al., 1979), but this evaluationis restrictedto laboratorieswith expertise with this technique and is not routinelyavailable.Immunophenotypingprotocols(Wells et al., 2003; Kussicket al., 2005; van de Loosdrechtet a]., 2008) and microarraytechniques(Walkeret al., 2002; Gondek et al., 2008), including array comparativegenomic hybridization(aCGH) and single

CLINICAL CORRELATIONS

143

nucleotide polymorphism (SNP) arraysto detect copy neutral loss of heterozygosity (LOH), may also help clinical decision making in the future.

CLINICAL CORRELATIONS For the clinician, cytogenetic analysis plays a vital role in the managementof MDS, includingconfirminga subtlediagnosis,prognostication,andselectingappropriatetherapy, At the time of diagnosis, recurringchromosomalabnormalitiesare found in 40-7096 of patientswith primaryMDS and in 95%of patientswith t-MDS (Vallespi et al., 1998), and theiridentificationconfirmsthe presenceof a neoplasticprocess. The value of cytogenetic analysis in predicting survival and the risk of leukemic transformationduring a patient’s clinical course has been well established (Morel et al., 1993; Toyama et al., 1993; Jotterandand Parlier, 1996; Sol6 et al., 2005; Haase et al., 2007). Among the few independentvariablesidentifiedthatpredictclinicaloutcomes in MDS, cytogeneticfindingsformthe cornerstoneof successfulprognosticscoringsystems (Greenberget al., 1997;Malcovatiet al., 2007). Themostvalidatedsystem,the International PrognosticScoringSystem (IPSS)(Greenberget al., 1997), identifiedmarrowblast count, numberof peripheralcytopenias,and cytogenetic findingsas the variablesmost useful in prognostication(Table6.2). Its applicationis limited to the time of diagnosis.The WHO diagnosticclassification integratesthe characteristicsof the first two elements into the diagnosis. In the WHO prognosticscoring system (WPSS), the groupingof these entities can be used with the IPSS cytogenetic risk groupsas well as the clinical need for blood transfusionto determinea moredynamicprognosticscore.The WPSShas the advantageof being a time-dependentsystem that can be used throughoutthe course of the disease (Malcovatiet al., 2007). In lowerriskpatients,additionallaboratoryfindings(suchas ferritin and P2-microglobulinlevels) may help identifythose patientswith a worse prognosiswho may benefit from early therapeuticinterventions(Garcia-Manero et al., 2008). With larger datasets, morerarerecurringcytogeneticabnormalitiesmay be examinedallowinga refining of the cytogeneticrisk groupsand providingthe clinicianswith moreinformationto predict the expectedoutcomefor theirpatient,albeitwith the caveatsassociatedwith retrospective studies(Haaseet al., 2007). Thefrequencyof cytogeneticabnormalitiesincreaseswith theseverityof disease,as does the risk of leukemictransformation.Clonal chromosomeabnormalitiescan be detected in marrowcells of 25%of patientswith refractoryanemia(RA), 10%of patientswith refractory anemiawith ringed sideroblasts(RARS), 50%of patientswith refractorycytopeniaswith multilineagedysplasia(RCMD),50-70% of patientswith refractoryanemiawith excess of blasts 1.2 (RAEB-1,2), and 100%of patientswith MDS with isolateddel(5q).

TABLE 6.2 CytogeneticAbnormalitiesin the InternationalPrognosticScoringSystem

Favorable risk tnteimediate risk Poor risk

Cytogenetic Abnormalities Normal karyotype, isolated del(5q), isolated del(2Oq). isolated -Y Other abnormalities -7/de1(7q), complex karyotypes

25% AML Progression 5.6 years

Median Survival 3.8 years

1.6 years 0.9 years

2.4 years 0.8 years

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MYELODYSPIASTIC SYNDROMES

Therapeuticoptionsare increasingin MDS patientsas severalagentsarenow approved fortheircareby variousregulatoryagencies.Althoughcytogeneticanalysishasalwaysbeen used to establish prognosis, which dictated therapeuticdecisions in a general sense (supportivecare versus remission-inducingcytotoxic chemotherapyregimens),a new era of targetedtherapy was launched with the recognition of the sensitivity of MDS with PDGFRB translocationsto the tyrosine kinase inhibitor imatinib mesylate (Apperley et al., 2002) and of MDS with del(5q) to the immunomodulatingdrug lenalidomide(List et al., 2006). With further molecular understandingof the underlying abnormalities, treatmentof patientswill ideally be individualizedaccordingto the specific chromosomal abnormalitiesunderlyingthe diseaseprocessin each case andnovel treatmentsare currently being developedtowardthis end.

CYTOGENETIC ANALYSIS A numberof recurringcytogeneticabnormalitieshave been identifiedin MDS (Table6.3). Thesefindingsarenotexclusiveto MDS andmay also be seen in AML(Chapter5 ; Mitelman et al., 2008). Mostrecurringcytogeneticabnormalitiesfoundin MDS areunbalanced,most commonly the result of the loss of a whole chromosome or a deletion of part of a chromosome,but unbalancedtranslocationsand more complex derivative(rearranged) chromosomes can also be found (Figs 6.1 and 6.2). The most common cytogenetic abnormalitiesencounteredin MDS are del(5q), -7, and 8, whichhave been incorporated into the morerobustprognosticscoringsystemsof MDS. Clones with unrelatedabnormalities, one of which typicallyis gain of chromosome8, areseen at a greaterfrequency(-5% versus -I %) in patientswith MDS than in patientswith AML. A handfulof specific cytogeneticabnormalities,includingthe 5q- syndrome(Van den BergheandMichaux, 1997), the 17p- syndrome(Jary et al., 1997), and the isodicentricX chromosome(that is associated with RARS with a high likelihood of transformationto AML) (Dewald et al., 1982), are associated with morphologicallyand clinically distinct subsets of MDS. In rare cases, recurringbalanced translocationshave been reported. Abnormalitiescharacteristicof acuteleukemiawithouta priormyelodysplasticphase,such as the t( I5;17), inv(16), and t(8;21), are rarely identified in MDS (Rowley, 1999). The

+

Primary MDS

t-MDS 9%

a Normal

karyotype

Balanced abnormalities

Other unbalanced abnormalities Abnormal chromosome 5 andlor 7

FIGURE 6.1 Type of karyotypic abnormalities in MDS.

~~

~

~

_

_

i( 1 7p) -13/del(13q) del(1lq) del(12p)/t(12p) del(9q) idic(X)(ql3) Balanced t( 1;3)(p36.3;q21) t(2;l l)(p21;q23)/t(l lq23) inv(3)(q21q26.2) t(6;9)(p23;q34)

-Y

Unbalanced +8 -7/de1(7q) -5/del(5q) del(20q)

1% 1% 1% 1%

10% 10% 10% 58% 5% 3-5% 3% 3% 3% 1-2% 1-2%

ChromosomeAbnormality Frequency

RPL22LI MU PDGFRB

RPNI DEK

MMELl

TP53

Loss of function,DNA damageresponse

Deregulationof MMELl -transcriptional activation? MLL fusion protein-altered transcriptional regulation Fusion protein Fusion protein-nuclear pore protein

Loss of function

Consequence

regulation RUNX 1 fusion protein-altered transcriptional RUNXI CREBBP MLL fusion protein-altered transcriptional regulation EW6/TEL Fusion protein-altered signalingpathway

TP53

RPNI MLL MDSl/EVll NUP214

Involved Genesb

"MDS, myelodysplasticsyndrome;CMML,chronicmyelomonocytic leukemia. 'Genes are listed in orderof citationin the karyotype,for example, for the t(11;16), M U i s at 1 lq23 and CREBBPat 1 6 ~ 1 3 . 3 .

Therapy-related-7/de1(7q) 50% MDS -5/del(5q) 4045% di~(5~17)(~11.1-13~~11.1-13) 5% der(1;7)(q10;plO) 3% t(3;21)(q26.2;q22.1) 3% t( 11;16)(q23;~13.3)/t(l lq23) 2% CMML t(5;12)(q32;p13) 2-5 %

MDS

__

Disease*

TABLE 6.3 Recurring Chromosomal Abnormalities in Myelodysplastic Syndromes

146

MYELODYSPLASTIC SYNDROMES

Primary MDS

t-MDS/t-AML

FIGURE 6.2 Recumngchromosomalabnormalitiesin MDS

t(9;22), diagnosticof chronicmyeloid leukemia(CML)andsubtypesof acutelymphoblastic leukemia(ALL) as well as AML, has only rarelybeen reportedin MDS (Smadjaet al., 1989). In contrastto classicalchromosomebandinganalysis,fluorescencein situ hybridization (FISH)can evaluateinterphaseas well as metaphasecells in a rapidand efficient manner (Kearney, 1999; Gozzetti and Le Beau, 2000). The primaryadvantageof FISH is the simplified analysis permittingthe evaluationof a highernumberof cells, therebygreatly increasingthe sensitivity.It can also be appliedto histologicalpreparations allowinga direct correlationof the statusof the genetic targetwithin morphologicallycharacterizedcells. However,the techniqueevaluatesspecific alterationsbased on probeselection ratherthan the entirechromosomalcomplement.Probessuitableforclinical use arenot availableforall recurringabnormalitiesof interest,and variationin thecytogeneticabnormality(witheither complex rearrangements or differencesin breakpoints)may not be detectedwith conventional probes. In MDS, commercially available probes have been developed for the detectionof 1 1q23 translocationsinvolving MLL (mixed lineage leukemia),-Y, -5/del (5q), -7/de1(7q), 8, del( I I q), del(I3q), - 1?'/loss of 17p, and del(2Oq).

+

CYTOGENETIC FINDINGS IN MDS Normal Karyotype A normalkaryotypeis found in 3 0 4 0 % of patientswith MDS. This groupof patientsis almostcertainlygeneticallyheterogeneous,wheretechnicalfactorsprecludedthedetection of chromosomal] y abnormalcells or where leukemogenic alterationsoccurred at the molecularlevel and were not detectablewith standardcytogeneticmethods.Nonetheless, despitethis heterogeneity,thesecases area standardreferencefor comparisonof outcomes. The InternationalMDS Risk Assessment Workshopfound that patients with a normal karyotypefall within the favorablerisk group. The median survival for these patientsis 3.8 years, and the time to progression to AML of 25% of this cohort was 5.6 years (Greenberget al., 1997).

CMOGENETICFINDINGS IN MDS

147

-Y The clinical and biological significanceof loss of the Y chromosome,-Y, is unknown. Loss of the Y has been observed in a numberof malignantdiseases but has also been reportedto be a phenomenonassociated with aging (Pierreand Hoagland, 1972). The UnitedKingdomCancerCytogeneticsGroup( 1992) undertooka comprehensiveanalysis of this abnormalityin bothnormalandneoplasticbone marrows.A -Y could be identified in 7.7%of patientswithouta hematologicmalignantdisease andin 10.7%of patientswith MDS and, thus, was not reliablein documentinga malignantprocess.In a studyof a large series of 215 male patients,those with a hematologicaldisease had a significantlyhigher percentageof cells with -Y (52% versus 37%, p = 0.036) (Wiktoret al., 2000). In that study,the presence of -Y in > 75% of metaphasecells accuratelypredicteda malignant hematologicaldisease. A neutralor favorableprognosisfor an isolated -Y was notedby the authors.While loss of a Y chromosome may not be diagnostic of MDS, once the disease is identified by clinical and pathologic means, the InternationalMDS Risk Analysis Workshop found that -Y as the sole cytogenetic abnormalityconferred a favorableoutcome (Greenberget al., 1997).

deN20q) A deletion of the long arm of chromosome 20, del(20q), is a common recurring abnormalityin malignant myeloid disorders. The del(20q) is seen in approximately 5%of MDS and7%of t-MDScases (Vallespiet al., 1998).Clinicalfeaturescharacterizing MDS patients with a del(20q) include low-risk disease (usually RA), a low rate of progressionto AML, and prolongedsurvival(medianof 45 monthsversus28 monthsfor otherMDS patients)(Wattelet al., 1993). Morphologically,the presenceof a del(20q) is associatedwithprominentdysplasiain the erythroidandmegakaryocyticlineages (Kurtin et al., 1996). The InternationalMDS Risk Analysis Workshopnoted thatpatientswith a del(20q) as part of a complex karyotyperepresenteda poor risk group with a median survivalfor the entire group of 9.6 months, whereas the prognosis for patientswith an isolated del(20q) was favorable(Greenberget al., 1997). These datasuggest that the del (20q) in MDS may be associated with a favorable outcome when noted as the sole abnormality,but with a less favorableprognosis in the setting of a complex karyotype. This is analogousto thatobservedalso for the del(5q) in MDS (discussedin the following section).

Loss of Chromosome 5 or del(5q) In MDS orAMLarisingde nova, loss of a whole chromosome5 ora deletionof its long arm, -5/de1(5q), is observedin 10-20% of patients,whereasit is identifiedin 40%of patients with t-MDS/t-AML(Fig. 6.3) (Vallespiet al., 1998;GodleyandLarson,2002). A significant occupationalexposureto potentialcarcinogensis presentin many patientswith AML or MDS de nova and either -5/de1(5q) or a -7/de1(7q) (discussedsubsequently),suggesting thatabnormalitiesof chromosome5 or 7 may be a markerof mutagen-inducedhematological malignantdiseases (West et al., 2000). In primaryMDS, abnormalitiesof chromosome5 are observedin the 5q- syndrome (describedbelow) or, morecommonly,in RAEB I , 2 of the WHO classificationas partof a complex karyotype.Clinically, the patientswith del(5q) coupled with other cytogenetic

148

MYELODYSPLASTIC SYNDROMES

5

del(5q)

7

del(7q)

FIGURE6.3 Deletions of 5q and 7q in myeloid neoplasms. In this del(5q), breakpointsoccur in 5q14 and 5q33 resulting in interstitialloss of the interveningchromosomal material.In this del(7q), breakpointsoccur in 7q 1 1.2 and 7q36. In both cases, the criticalcommonly deleted segmentsare lost. Normal chromosome5 and 7 homologues are shown for comparison.

abnormalitieshave a poor prognosis with early progression to leukemia, resistanceto treatment,andshortsurvival.Abnormalitiesof 5q areassociatedwith previousexposureto standardandhighdose therapywith alkylatingagents,includinguse in immunosuppressive regimens&arson et al., 1996; Aul et al., 1998; McCarthyet al., 1998; Pedersen-Bjergaard et al., 2000). A role for exposureto benzene (Hayes et al., 1997) as well as therapeutic ionizingradiation(Fenauxet al., 1989; Rowley andOlney, 2002) as risk factorsfor MDS is emerging.

The 5q- Syndrome The 5q- syndromerepresentsa distinctclinicalentitycharacterizedby a del(5q)as the sole karyotypicabnormality(Boultwood et al., 1994; Van den Berghe and Michaux, 1997). Unlike the male predominancein MDS in general,the 5q- syndromehas an overrepresentationof females (2:1). The initial laboratoryfindingsare usually a macrocyticanemia with a normalor elevated platelet count. The diagnosis is usually RA (in two-thirds)or RAEB (in one-third).On bone marrowexamination,abnormalitiesin the megakaryocytic lineage(particularlymicromegakaryocytes) are prominent.These patientshavea favorable outcome,in fact the best of any MDS subgroup,with low ratesof leukemictransformation and a relativelylong survivalof severalyearsduration(Boultwoodet al., 1994; Greenberg et al., 1997). The loss of a single copy of the RPSf4 gene may be involved in the pathogenesisof this syndromeas describedsubsequently(Ebertet al., 2008). +8

The incidenceof a gain of chromosome8 in MDS is 10%.This abnormalityis observedin all MDS subgroupsvaryingwith age, gender,and priortreatmentwith cytotoxic agentsor radiation(Morelet al., 1993; Greenberget al., 1997; Vallespi et al., 1998; Paulssonet al., 200 I). It can occur as both a constitutionaland an acquiredabnormalityand can fluctuate throughoutthe disease course (Mastrangeloet al., 1995; Matsudaet al., 1998; Maserati et al., 2002). The significanceof the gain of chromosome8 in MDS, includingits prognostic impact,is not clear-The situationis complicatedin that 8 is often associatedwith other recurringabnormalitiesknownto have prognosticsignificance,forexample,-5/del(Sq) or -7/de1(7q), andmay be seen in isolationas a separateclone unrelatedto theprimaryclone in N

+

CYTOGENETICFINDINGSIN MDS

149

upto 5% of cases. The presenceof crypticabnormalitiesatothersites withinthegenomehas also been describedin some cases using molecularmethods(Paulssonet al., 2006), which may explain thevariabilityin the clinical coursereportedin patientswith trisomy 8. The InternationalMDS Risk Analysis Workshoprankedthis abnormalityin the intermediate risk group (Greenberget al., 1997), and this rankingremainsunchangedwith the newly proposedtime-dependentscoreof the WPSS (Malcovatiet al., 2007). In univariateanalysis, one largestudyfound thatcases with 8 as a sole abnormalityhad a worse behaviorthan expected for an intermediateIPSS risk group, which was also the case in a large retrospectivestudy (Sol6 et al., 2000; Haaseet al., 2007). This latterstudyfound thatthe prognosis improvedwith one additionalabnormality,but worsened with more than one additionalabnormality.

+

Loss of Chromosome 7 or del(7q) A -7/de1(7q) is observedas the sole abnormalityin approximately5% of adultpatientswith de now MDS (Toyamaet al., 1993; Sol6 et al., 2000) but in 4 0 % of childrenwith de nova MDS (Kardoset al., 2003) and in -55% of patientswith t-MDS (Fig. 6.3) (Godley and Larson, 2002). It can occur in three clinical settings (reviewed in Luna-Fineman et al., 1995): (1) de novo MDS and AML;(2) myeloid leukemiaassociatedwith constitutionalpredisposition;and (3) t-MDS/t-AML.The similarclinical andbiologicalfeaturesof the myeloid disordersassociatedwith -7/de1(7q) suggest that the same gene(s) is altered in each of these contexts. The IPSS considers the -7/de1(7q) to be a poor prognostic cytogeneticfinding (Greenberget al., 1997). A “monosomy7 syndrome”has been describedin young children.It is characterizedby and a preponderance of males (4: 1), hepatosplenomegaly,leukocytosis,thrombocytopenia, a poor prognosis(Emanuel, 1999; Martinez-Climentand Garcia-Conde,1999). Juvenile myelomonocytic leukemia (JMML,previously known as juvenile chronic myelogenous leukemia)is a myelodysplasticsyndrome/myeloproliferative disease (MDS/MPD) in the WHO classificationand shares many featureswith this entity; -7 is observed either at diagnosisor as a new cytogeneticfindingassociatedwith disease accelerationon marrow examination(Luna-Finemanet al., 1995).An emergingparadigmis that-7 cooperateswith deregulatedsignalingvia the RAS pathwayin the pathogenesisof JMML.Activationof the RAS pathway occurs as a result of mutationsin the NRAS or KRAS gene, inactivating mutationsin the gene encoding NF1, a negative regulatorof RAS proteins,or activating mutationsin the gene encodingthePTPN 1 1/SHF’2 phosphatase,a positiveregulatorof RAS proteins.In constitutionaldisordersassociatedwith a predispositionto myeloid neoplasms, includingFanconianemia,neurofibromatosistype 1, and severe congenitalneutropenia, a -7/de1(7q) is the most frequentbone marrowcytogeneticabnormalitydetected.As with -5/de1(5q), occupationalor environmentalexposureto mutagensincludingchemotherapy, radiotherapy, benzeneexposure,andsmoking(Bjorket al., 2000), as well as severeaplastic anemia (regularlytreated with immunosuppressiveagents alone), have been associated with -7/de1(7q).

The l7p- Syndrome Loss of the shortarm of chromosome17 (17p-) has been reportedin up to 5% of patients with MDS. This loss can resultfrom various abnormalities,includingsimple deletions, unbalancedtranslocations,dicentricrearrangements (particularlywith chromosome5), or less often -17 or isochromosomeformation (Johanssonet al., 1993). The dic(5;17)

1!%

MYELODYSPLASTICSYNDROMES

(qll.l-l3;pll.l-l3) is a frequentlyrecurringrearrangement(Lai et al., 1995; Wang et al., 1997). Approximately one-third of these patients have t-MDS (Merlat et al., 1999), and most have complex karyotypes.The most common additionalchanges are -7, or loss of 7q, and 8. Morphologically,the 17p- syndrome is associated with a characteristicform of dysgranulopoiesiscombining pseudo-Pelger-Hue1hypolobulationand the presence of small granules in granulocytes.Clinically, the disease is aggressive with resistance to treatmentand short survival.The TP53 gene, an importanttumor suppressorgene that functionsin the cellularresponseto DNA damage,is locatedat 17pl3.1. In thesecases, one allele of TP53is typicallylost as a resultof the abnormalityof 17p;an inactivatingmutation in the second allele on the remainingmorphologicallynormalchromosome17 occursin -70% of cases (Lai et al., 1995; Wang et al., 1997).

+

Translocations of 11q23 The MLL gene (also known as ALLl, HTRX, HRX) is involved in over 50 reciprocal translocationsin acute leukemia(Zhangand Rowley, 2006). In a Europeanworkshopof 550 patientswith I 1 q23 abnormalities,28 cases (5. I %) presentedwith MDS and 5 others with such an abnormalityhad evolved fromt-MDS to t-AML priorto cytogeneticanalysis, for a total of 6% of all cases examined. One-fourthof these cases had t-MDS (Bain et al., 1998). Other abnormalities,including complex karyotypes and a -7/de1(7q), frequentlyaccompanythe 1 lq23 abnormalitiesin both primaryMDS and t-MDS. No associationwith any FAB subgroupwas identified,althoughRA was overrepresented,and RARS was underrepresentedas comparedto most series of MDS patients.The median in -20% of cases. Theclassic survivalwas short( 19 months)with leukemictransformation associationof priorexposureto topoisomeraseI1 inhibitorswith thedevelopmentof t-MDS/ t-AML with translocationsof 1 lq23 was not confirmed in this workshop,but this may simply reflect the relatively small number(n=23) of cases with full treatmentdetails (Secker-Walker,1998). Slightly less than 12% of the 162 patients with 1 lq23 involvementincluded in an InternationalWorkshopon MDS and Leukemiafollowing cytotoxic treatmentpresented with at-MDS(Bloomfieldet al., 2002; Rowley andOlney,2002). One-third(6/19) of these patientshadprogressionto acuteleukemia(5 AML, 1 ALL). This studyalso did not find a clear associationwith FAB subtype.The most common translocationswere t(9;l l)(p22; q23) in six cases, t( 1 1 ;19)(q23;p13.1) in three cases, and t( I 1 ;16)(q23;p13.3) in three cases.

t(11;16) Thet(1 I ;16)(q23;p13.3) occursprimarilyin t-MDS,butrarecases havepresentedas t-AML (Fig. 6.4) (Rowley et al., 1997). The t( 1 1 ;16) is uniqueamongover50 recurringtranslocationsof M U in myeloid malignancies(withAMLpredominating)in thatmost patientshave t-MDS. The M U gene on chromosome 1 I is fused with the CREBBP (CREB binding protein)gene on chromosome 16. The MLL protein is a histone methytransferasethat assemblesin proteincomplexesthatregulategene transcription of, forexample,HOXgenes duringembryonicdevelopment,via chromatinremodeling.CREBBPis a histone acetyltransferaseinvolved in transcriptionalcontrol via histone acetylation,which mediates chromosomedecondensation,therebyfacilitatingtranscription.Both genes have multiple

CYTOGENETIC FINDINGS IN MDS

p13.3-

11

der(l1)

151

4

16

der(l6)

FIGURE 6.4 t( 1 1; 16)(q23;p13.3).In the t(1 I; 16), breakpoints occur in 1 lq23 and 16~13.3,followed by a reciprocal exchange of chromosomal material. The 5’ end of the M U gene at 1 1423 is fused to the 3‘ end of the CREBBP gene from 16~13.3to form the MWCREBBP fusion gene on the der(l1). Arrowheads indicate the breakpoints. Normal chromosome 1 1 and 16 homologues are shown for comparison.

translocationpartnersin varioushematologicaldisorders;thus,elucidatingtheirfunctionis providingnew insightsin leukemiaresearch.

Complex Karyotypes Complex karyotypes are variably defined, but generally involve the presence of 2 3 chromosomalabnormalities.The majority of cases with complex karyotypes involve unbalancedchromosomalabnormalitiesleading to the loss of genetic material.Complex karyotypesareobservedin -20% of patientswith primaryMDS and in as many as 90%of patients with t-MDS (Le Beau et al., 1986; Godley and Larson, 2002). Abnormalities involvingchromosomes5,7, or both areidentifiedin most cases with complexkaryotypes. Thereis generalagreementthata complexkaryotypecarriesa poorprognosis(Hamblinand Oscier, 1987; Greenberget al., 1997; Haase et al., 2007; Malcovatiet al., 2007).

Rare Recurring Translocations The identificationof genes involved in recurringcytogenetic abnormalitieshas been extremelyuseful in gaininginsightsinto theirnormalfunctionsand theirrole in leukemogenesis (Look,1997;Rowley, 2000). The consequenceof therecurringtranslocationsis the deregulationof gene expressionwith increasedproductionof a normalproteinproductor, morecommonly,thegenerationof a novel fusiongene andproductionof a fusionprotein.To date, all of the recurringtranslocationscloned in malignantmyeloid disordersresultedin fusionproteins.In MDS, severalsuch translocationshave been identifiedandexaminedby molecularanalysis.

The Platelet-DerivedGrowth Factor Receptor Beta Translocations The t(5;12)(q32;p13)is observedin -1% of patientswith CMML.In 1994, the molecular consequencesof this translocationwere elucidated.The involved gene on chromosome5 encodesthe beta chain of the platelet-derivedgrowthfactorreceptor(PDGFRB).A novel ETS-like (erythroblastosisvirus transformingsequence)transcriptionfactor, TEL (translocatedETSin leukemia,also knownas ETVQ, is the gene affectedon chromosome12. The translocationcreatesa fusion gene, andthe encodedfusion proteincontainsthe 5’ portionof

152

MYELODYSPLASTIC SYNDROMES

TEL and the 3' portionof PDGFRB (Golubet al., 1994).Biochemicalstudieshaverevealed that the PDGFRBkinase activity is perturbedcontributingto the transformedphenotype. TEL encodes a transcriptionalrepressorand is promiscuouslyinvolved in translocations with some 40 genes in hematologicmalignancies(Zhangand Rowley, 2006). Interesthas increased in identifying this translocation,which predicts for a response to imatinib mesylate, a selective inhibitorof the tyrosine kinase activity of the PDGFRB protein (Apperley et al., 2002). Similarly, PDGFRB participatesin other rare translocations involving genes encodingthe membrane-associated proteinHIP1 (Huntingtoninteracting protein1) in the t(5;7)(q33;q1 1.2) (Rosset al., 1998),the smallGTPaseRABEP1 (Rabaptin I ) in the t(5;17)(q33;pl3) (Magnussonet al., 2001). CCDC6, a ubiquitouscoiled-coil domain protein of unknown function in the t(5;10)(q33;q21) (Kulkami et al., 2000) observedin CMML,and CEV14 (clonal evolution-relatedgene on chromosome14, also known as TRIP11, thyroidhormonereceptorinteractorI 1) in t(5;14)(q33;q32)in a case of AML (Abe et al., 1997). A unifyingphenotypicfeatureof thesevarioustranslocationsis the presenceof eosinophilia.

Translocations of 3q The t(3;21)(q26.2;q22.I ) has been linked to acute leukemia arising after cytotoxic therapy.This abnormalitywas first recognized in CML in blast crisis (Rubin et al., 1987) butlaterin t-MDS/t-AML(Rubinet al., 1990). TheRPL22Ll (EAP)gene (EpsteinBarrsmall RNAs-associatedprotein)at 3q26.2 encodes a highly expressedsmall nuclear proteinassociated with EBV small RNA (EBERI).RPL22Ll was foundto be fused with the RUNXl (Runt-relatedtranscriptionfactor, also known as AMLI) gene at 21q22.1, retainingthe DNA bindingsequences of RPL22LI.The fusion is out-of-frame;thus, the R U N X l gene is truncatedandloses its functionalactivity.Furtherwork has identifiedtwo additionalgenes 400-750 kb centromericto RPL22L1, also at 3q26.2, namely, MDSI/ EVIl (MDS-associated sequences) and EVll (ecotropic virus insertionsite) (Nucifora et al., 1994). Both genes encode nucleartranscriptionfactors containingDNA binding zinc fingerdomains,which are identical.otherthan an N-terminalextensionof 12 amino acids in the MDSl/EVIl protein, representing a splicing variant. Each gene has independent and tightly controlled expression during differentiation (Sitailo et al., 1999). The MDSI/EVI1 andEVIl proteinshave opposite functions.EVIl inhibits G-CSF-mediateddifferentiationand TGFP1 growth-inhibitoryeffects, whereasMDS I/ EVI1 has no effect on G-CSFandenhancesTGFPI growthinhibition(Sitailoet al., 1999). RUNXI fuses with MDSI/EVZl in-frame,resultingin the loss of the first 12 aminoacids, producinga novel EVII proteinanda phenotypeof arresteddifferentiation,which leadsto apoptosisin vitro (Sood et al., 1999). MDSl/EVIl serves as a translocationpartnerwith the ribosome binding protein RPNI (ribophorin1 ) (Martinelliet al., 2003) and/or the C30RF27 gene encoding a poorly characterizedprotein in fetal development(Pekarsky et al., 1997) in the inv(3)(q21q26.2)or the t(3;3)(q21;q26.2)associated with normalor increasedplatelet counts,as well as with TEL (Raynaudet al., 1996) (discussedabove) in the t(3;12)(q26.2;p13). Common featuresof myeloid diseases associatedwith abnormalities of 3qarea previoushistoryof cytotoxic exposure,prominentbone marrowdysplasia, and a poorprognosis.Abnormalitiesof chromosome7 [-7/de1(7q)J areobservedin most cases with rearrangementsof 3q. In an InternationalWorkshopon Therapy-Related Hematologic Disease, inv(3)/t(3;3) abnormalities were the most frequent of the 3q abnormalities(Block et al., 2002).

THE MYELODYSPIASTlC/MYELOPROLlFERATlVEDISEASES

(MDSIMPD)

153

EVOLUTION OF THE KARYOTYPE Serial evaluationscan be informative,particularlywhen there is a change in the clinical featuresof a case. The identificationof new abnormalitiesin the karyotypeoften coincides with a changein the behaviorof the disease, usually to a moreaggressivecourse,and may heraldincipientleukemia.Cytogeneticevolution is the appearanceof an abnormalclone where only normalcells were seen previously,or the progressionfrom thepresenceof a single clone (often with a simplekaryotype)to multiplerelated,or occasionallyunrelated, abnormalclones. The abnormalclones may evolve acquiringadditionalabnormalitieswith disease progression,andtypically resolvewith remissionof diseasefollowingtreatment.In publishedseries, most MDS patientsdie of bone marrow failure,close to half progressto acute leukemia,and a few die of intercurrentillness. The naturalhistoryof MDS is generallycharacterizedby one of threeclinical scenarios: (1) a gradualworsening of pancytopeniawhere the marrowblast count is found to be increasing;(2) a relativelystableclinical coursefollowed by an abruptchangewith a clear or (3) a stablecourseovermanyyearswithoutsignificantchange leukemictransformation; in the marrowblastcountswhen reevaluated(HamblinandOscier, 1987). In the firstgroup, the karyotypetypically remains stable, and the progressionto leukemiais based on the relativelyarbitraryfindingof greaterthan20%blasts(30%in the FAB classification)in the marrow,makingthe transitionto AML a relativelyill-definedevent. In the second group,a changein the karyotypewiththeemergenceof secondaryclones andcomplexkaryotypesis typical. Both the karyotypeand the disease tend to remainstablein the third group. Few series with sequentialcytogeneticstudies have been published,and most series are small with shortfollow-upperiods(Horiikeet al., 1988;Geddeset al., 1990;de SouzaFernandez et al., 2000). Nonetheless,karyotypicevolutionin MDS is associatedwith transformationto acute leukemiain about60%of cases and reducedsurvival,particularlyfor those patients who evolve within a short period of time (less than 100 days) (Geddeset al., 1990).

THE MYELODYSPLASTIC/MY ELOPROLIFERATIVE DISEASES (MDS/MPD) The WHO has recognizedthe existence of diseases thatpresentwith dysplasticas well as proliferativefeatures (JafTeet al., 2001). These entities can behave clinically as overlap syndromeswith featuresof both myelodysplasiawith complicationsrelatedto ineffective proliferationof one or more myeloid lineage, togetherwith featuresof chronicmyeloproliferative disease with organ infiltration(frequentlythe liver and spleen) and elevated circulatingleukocyte counts of at least one myeloid lineage. Patientsmay present with featuresanywherealong the continuumbetweenthese two myeloiddiseases.However,the developmentof dysplasiaandineffectivehematopoiesisduringthecourseof a classic MPD does not warrantreclassificationinto this category of diseases. As in MDS, the marrowis hypercellularwith fewerthan20%blasts.Definingthe molecularpathwaysinvolved in the MPDMPDoverlapdisordersis an active areaof research,and will ultimatelylead to their reclassificationwhen theiretiologies andpathogenesisbecome betterunderstood(Adeyinka and Dewald, 2003; Vardiman,2003). The MDSMPD category of the WHO includes chronic myelomonocytic leukemia, atypicalchronicmyeloidleukemia(aCML).juvenilemyelomonmyticleukemia,andMDS/ MPD unclassifiable(Jaffe et al., 2001). The defining feature of CMML is peripheral monocytosisof greaterthan 1 x 109/L.with dysplasiain one or more lineages. In aCML,a

154

MYELODYSPLASTICSYNDROMES

peripheralmyeloid expansion with typically > 10% immature elements and severe dysplasia,particularlyin the granulocyteswithouta significantbasophilia( < 2%),is found in the absenceof the t(9;22). JMMLpresentswith a combinationof bothelementsincluding monocytosis(> 1 x 109/L),leukocytosis,and typically a thrombocytosis,combinedwith significantvisceral organ infiltration(Hasle, 2007).

Cytogenetic Abnormalities in MDSMPD Thereareno genetic alterationsthatarespecific for this groupof disease. The absenceof thet(9;22) resultingin the fusion of BCR andABLl necessaryfor thediagnosisof CMLis a key diagnosticelement. The common abnormalitiesseen in MDS are also seen in MDS/ MPD. Thereis, however,a markedlylowerincidenceof -5/de1(5q) as well as abnormalities of 1l q comparedto the classical formsof MDS (Adeyinkaand Dewald, 2003). In all cases, the most frequentabnormalitiesinclude the gain of chromosome8 and abnormalitiesof chromosome7. Loss of the Y chromosomeis seen in many cases, butmay representan ageassociatedphenomenonratherthana pathogeneticassociation.The involvementof 12p in variousrearrangementsin CMMLis also a frequentfinding ( > 5%) (GroupeFrancaisde CytogenetiqueHematologique,199I ). As discussed above, translocationsof PDGFRB (5q32) are noted in rarecases of CMMLand aCML(1-2%), and theirunifying featureis eosionophilia.InJMML,theonly frequentlyrecurringabnormalityis -7/de1(7q), whichhas beenreportedin 6 2 0 %of cases, usuallyas the sole cytogeneticabnormality(Luna-Fineman et al., 1995). The MDS/MPDunclassifiablecases do not have specificrecurringabnormalities and cytogeneticsis useful in excludingCMLandestablishingclonalityof the disorder.

THE GENETICS OF THE MYELODYSPLASTIC SYNDROMES

Molecular Models for Chromosome Abnormalities in MDS As describedearlier,many of the recurringchromosomalabnormalitiesin MDS lead to the loss of genetic material.The genetic consequencesof a deletion may be a reductionin the level of one ormorecriticalgene products(haploinsufficiency)orcompleteloss of function. The lattermodel, known as the “Knudsontwo-hitmodel,” predictsthatloss of functionof both alleles of the target gene would occur, in one instance through a detectable chromosomalloss or deletion and in the otheras a resultof a subtleinactivatingmutation or via anothermechanism,such as transcriptionalsilencing (Knudson,1971). A clinical example to illustratethis principleis t-MDS/t-AML. The relatively long latency period betweenthe timeof exposureandt-MDS/t-AMLwith abnormalitiesof chromosomes5 or7 (-5 years) is compatiblewith a two-step mechanismin which two mutationsof a target gene must occur in a stendprogenitorcell. These patientsmay have two normalalleles initially,one of which is mutatedas a resultof therapy.Subsequentloss of the otherallele in a bone marrowstem cell would contributeto leukemogenesis.Alternatively,because t-AML develops in only 510% of patients who are treatedfor a primarytumor,these individuals may have inherited a predisposing mutant allele; subsequentmutagenic exposure may induce the second mutation, giving rise to leukemia. In these cases, characterizationof the predisposingmutationswill be importantin identifyingindividuals who areat risk of developingt-AML andin the selectionof the appropriatetherapyforthe primarymalignantdisease.

THE GENETICSOF THE MYELODYSPLASTICSYNDROMES

155

In an alternativemodel, loss of only a single copy of a gene may resultin a reductionin the level of one or more critical gene products(haploinsufficiency).There is growing evidence that a numberof leukemia-relatedgenes are haploinsufficient,for example, TP53, SPII/PU.I, and RUNXI (Fero et al., 1996; Venkatachalamet al., 1998; Song et al., 1999;Frenchet al., 200 1;Rosenbaueret al., 2004). Inhumans,haploinsufficiencyof theRUNXI gene resultsin a familialplateletdisorderwith a predispositionto AML (Song et al., 1999; Michaudet al., 2002; Nakao et al., 2004). Importantly,the few leukemias availablefor analysisfrom affectedfamily membersappearto retainone normalRUNXI allele, Evidenceforthis mechanismwas providedby the subsequentidentificationof point mutationsin the RUNXl gene in sporadiccases of MDS and AML (Nakao et al., 2004). Despite intensiveefforts,neitherhomozygousdeletions norinactivatingmutationsin the remaining allele of candidategenes located within the commonly deleted segments (CDSs)have been detectedin myeloid leukemiacells characterizedby deletionsof 5q, 7q, or 20q in MDS and AML.This observationis compatiblewith a haploinsufficiencymodel in which loss of one allele of the relevantgene (orgenes) alterscell fate.Finally,it remains theoreticallypossible that loss of functionof differentgenes on 5q may contributeto the pathogenesis of AML, or that loss of more than one gene, that is, a contiguous gene syndrome,is necessaryto give rise to the characteristicfeaturesof MDWAMLwith a -5/ del(5q) or the 5q- syndrome.

Molecular Analysis of the del(5q) Several groupsof investigatorshave delineateda commonly deleted segmenton the long arm of chromosome5 predictedto containa myeloidtumorsuppressorgene thatis involved in the pathogenesisof MDS andAML (Fig. 6.5) (Le Beauet al., 1993;Fairmanet al., 1995; Zhaoet al.. 1997;Jajuet al., 1998;Homganet al., 2000). By cytogeneticandFISHanalysis, Zhaoet al. (1997) delineateda 970 kb CDS within5q31 flankedby D5S479 and D5S500. Molecularanalysisof 20 candidategenes withinthe CDS of 5q3I did not revealinactivating

Commonly Deleted Segment of 5q

FIGURE 6.5 Idiogramof the long arm of chromosome 5 showing chromosome markersand candidategenes within the commonlydeleted segments(CDSs)as reportedby various investigators. TheproximalCDS in 5q3 I was identifiedin MDS, AML, andt-MDS/AML,whereasthe distalCDS in 5q32-33 was identified in the 5q- syndrome.

156

MYELODYSPIASTICSYNDROMES

mutationsin the remainingalleles,norwas thereevidenceof transcriptional silencing(Zhao et al., 1997;Lai et al., 2001; GodleyandLe Beau, unpublisheddata).Theseobservationsare compatiblewith a haploinsufficiencymodel, and severalcandidatehaploinsufficientgenes have been identifiedon 5q. One such candidateis theearlygrowthresponse1 gene (EGRI). EGRI , a memberof the WTl family of transcriptionfactors,is an early responseproteinin mediatingthe cellular responseto growth factors, mitogens, and stress stimuli, and is downstreamof cytokine signalingpathways.EGRl is a directtranscriptionalactivatorof TP53 and CDKNlMp21. J o s h et al. (2007) demonstratedthat loss of a single allele of Egrl cooperates with mutationsinducedby an alkylatingagent in the developmentof myeloid diseases in mice. Liu et al. (2007) demonstratedthat the gene encoding alpha-catenin(CTNNAI,located 285 kb distalto theCDS definedin 5q3I ) is expressedat lowerlevels in AML orMDS with a del(5q) than in other AML or normalhematopoieticstem cells. Moreover,restorationof CTNNAI expressionin HL-60 cells (used as a model for AML with loss of 5q) resultedin reducedproliferationand apoptoticcell death.Thesestudiesraisethe possibilitythatloss of expression of EGRl and CTNNAl in hematopoietic stem cells may contributeto the pathogenesisof MDS or AML with a del(5q). Molecularanalyses of the 5q- syndrome suggestthat a differentregion is involved. Boultwoodet al. (2002) identifieda 1.5 MbCDS within5q32 betweenD5S4I 3 andGLRAZ, which contains44 genes. This regionis distalto the CDS in 5q31 foundin the patientswith RAEB-I , RAEB-2, and AML with del(5q). Ebertet al. (2008) used an RNA interference screento reduceexpressionlevels of each candidatetumorsuppressorgene associatedwith the 5q- syndromeand identified the gene encoding RPS14, a ribosomal protein, as a candidate myeloid leukemia gene. They also demonstratedthat expressing RPS14 in CD34 cells from patients with the 5q- syndrome enhancederythroiddifferentiation and normalizedthe activation level of genes specifically expressed in red blood cell precursors.RPS14 is an essential componentof the 40s subunitof ribosomes (sites of proteinsynthesis),and ribosomesynthesisis impairedin CD34+ cells from5q- syndrome patients. Of note, two other ribosomal genes-RPSI9 and RPS25-are mutated in individualswith Diamond Blackfan anemia, a congenital form of anemia that shares severalfeatureswith the 5q- syndrome(Ebertet al., 2008). Together,theseresultsprovide strongevidence that RPSI4 functionsas a haploinsufficienttumorsuppressorgene in the 5q- syndrome.Whetherall patientswith the 5q- syndromehave involvementof RPSl4, and whetherthis gene plays a role in the pathogenesisof othersubtypesof MDS or AML, remainsto be determined. In summary,theexistingdatasuggestthattherearetwo nonoverlappingCDS in 5q31 and 5q32. The proximalsegmentin 5q31 is likely to containa tumorsuppressorgene involvedin the pathogenesisof both de novo and therapy-relatedMDS/AML. Band 5q32 containsa second myeloid tumorsuppressorgene involvedin the pathogenesisof the 5q- syndrome. +

Molecular Analysis of the -7/de1(7q) As with the -5/de1(5q), the breakpointsand extent of the deletionsof 7q in patientshave been examinedto identify a CDS (Kere, 1989; Johnsonet al., 1996; Le Beau et al., 1996; Fischeret al., 1997; Lianget al., 1998;Tosi et al., 1999). Datafromcytogenetic,FISH,and LOHstudiesperformedin a numberof laboratoriespainta complexpictureof 7q deletions in myeloid malignancies;however,thereis generalagreementthat7q22 is involved in the majorityof cases. Defining a consistentCDS has been hamperedby (1) the relativelylow

ALTERATIONSIN GENE FUNCTION

157

frequency of del(7q) comparedto the complete loss of chromosome7; (2) the use of differenttechniquesto investigatemarrowsamples,for example,FISHversusLOH;(3) the wide clinical spectrumof myeloid disorderswith alterationsof chromosome7, suggesting geneticheterogeneity;and(4) theexistenceof multipleand sometimescomplexcytogenetic abnormalitiesin most cases. By using cytogeneticand FISHanalysisof 81 patientswith de novo andtherapy-related MDS/AMLwitha del(7q),Le Beauet al. (1996) identifiedtwodistinctCDS, a 2.52 MbCDS within 7q22 spanningthe intervalcontaining LRCCl7 and SRPK2, and a second, less frequent,region in 7q32-33. Eachof the candidategenes within the CDS at 7q22 has been evaluatedfor mutations(Kratzet al., 2001; Curtisset al., 2005); however, no inactivating mutationshave been identifiedin the remainingallele. The identificationof a CDS within 7q22 is consistent with most published data (Kere, 1989; Lewis et al., 1996; Dohner et al., 1998). Tosi et al. (1999) evaluatedpatientswith 7q abnormalitiesand identifiedan interestingcase with a complex karyotypeand a t(7;7) who had a deletionassociatedwith the translocationbreakpointof 150kb spanning the CUTLZ locus in 7q22, slightly centromeric to the CDS defined by Le Beau and coworkers. Recently, Dohner et al. (2006) reportedthe analysis of a large series of patientswith abnormalitiesof 7q using FISH. Althoughmost patientshad largedeletions, they identifiedan -2 Mb deleted segmentin proximal7q22 thatoverlappedwith the proximalportionof the CDS definedby Le Beau et al. (1996) butextendedmoreproximallyandincludedthe CUTLl, RASAI, EPO, and FBXL13 genes in 7q22.1.

Molecular Analysis of the del(20q) The majorityof deletions in 20q are large with loss of most of the long arm,although cytogenetic analysis of the deleted chromosome 20 homologues has revealed that the deletions are variable in size. Using FISH analysis combined with LOH studies, investigatorshave identified an interstitialCDS of 4Mb within 2Oq12 that is flanked by D20S206 proximallyand D20S424 distally,containinga numberof genes. Despite the availabilityof detailed physical and transcriptmaps, the identity of a putativemyeloid tumorsuppressorgene on 20q remainsunknown(Bench et al., 2000; Wang et al., 2000). Recent studies have implicated the genes encoding topoisomerase 1 and lethal(3) malignantbrain tumor (L3MBTL), which is related to the Polycomb group family of transcriptionalrepressors.AlthoughL3MBTL is not mutatedin MDS, reducedor absent L3MBTLexpression may be relevantin some cases of myeloid leukemia (MacGrogan et al., 2004).

ALTERATIONS IN GENE FUNCTION A growing body of evidence suggests that mutations of multiple genes mediate the

pathogenesis and progressionof MDS. The involved genes fall into two main classes, namely, genes encoding hematopoietic transcriptionfactors or proteins that regulate cytokinesignalingpathways.Thereis an increasein the frequencyof molecularmutations from low-riskto high-riskMDS, or AML evolving from MDS, emphasizingthe role of thesemutationsin disease progression.Moreover,the progressionfromthe earlystagesof MDS to AML is often accompaniedby the acquisitionof molecularmutationsthat are known to play an importantrole in AML, for example,NRAS point mutations.A detailed

158

MYELODYSPLASTICSYNDROMES

TABLE 6.4 Frequency of Molecular Mutations in Myelodysplastic Syndromes MDS Subtype"

MutatedGene RA FLT3 (ITD) FLT3 (TKD) NRAS

K1F8l6 M U (ITD) RUNXI TP53 PTPNl I NPMl CEBPA JAK2

0% NA 10% 0 2% 4% NA NA NA NA Rare

RARS

0% NA 13% NA NA NA NA NA NA NA Rare

RAEB 2.5% NA

9% < 1% 3% 10% NA NA NA 4% Rare

RAEB-T

CMML

8% NA 13% 10% NA 15% NA NA NA NA Rare

4.5% NA 35% 0 3%

N

20% NA NA NA 10-20% 3%

MDS Total 2.4% I% 10-158 -1%

3% 10-15%

5- 10% -1% Rare I-8%

2-58

t-MDSIt-AML 0% < 1% 10% NA 2-3% 1530%

25-30% 3% 4-5% Rare 2-5%

"Note that the FAB nomenclature for MDS is used in this table, reflecting the available literature. RAEB-T, refractory anemia with excess blasts in transformation (reclassified as acute myeloid leukemia in the WHO classification). NA, not available.

review of these genes is beyond the scope of this chapter.Tables 6.4 and 6.5 provide a partial list and overview of some of the salient features of genes implicated in the pathogenesis of MDS. The RAS family is the most extensively studiedgene family in MDS. The RAS signaling cascadeis downstreamof a numberof activatedcytokinereceptors,includingthe FLT3,IL3, andGM-CSF receptors;thus, this signalingpathwayplays a pivotalrole in hematopoiesis. Constitutivelyactivatingpoint mutationsof NRAS have been detectedat high frequencyin hematologicalmalignancies.In MDS, NRAS mutations,typicallyinvolvingcodons 12, 13, or 61, have been detectedin 10-15% of cases. These mutationshave been associatedwith a poor prognosis with a higher incidence of transformationto AML and shortersurvival. Patientswith both abnormalkaryotypesandNRAS mutationshave the highestlikelihoodof transformation(Neubaueret al., 1994; Tien et a]., 1994; de Souza Fernandezet al., 1998; Paduaet al., 1998; Beaupreand Kurzrock,1999; Bacheret al., 2007).Targetedtherapies, includingthe farnesyltransferaseinhibitorsandimatinib,interruptvariousstepsin theRAS signalingpathways(Apperleyet al., 2002; Kurzrocket al., 2003). Mutationsof theFh4S-liketyrosinekinase3 (FLT3)gene, includingbothpointmutations within the tyrosinekinasedomainand internaltandemduplications(ITD), areamong the most common genetic changes seen in AML, occurringin 15-35% of cases. FLT3-ITD mutationsare associated with a poor prognosis, particularlyin cases with loss of the remainingwild-type FLT3 allele. In MDS, FLT3-ITDmutationsare rarein RA/RARS but increase to -3% and 12% in RAEB and AML following MDS, respectively (Bacher et al., 2007). Thus, FLT3-ITD may representa secondaryevent associated with MDS progressionratherthan the initiatingevent in MDS pathogenesis.Mutationsof the FLT3 tyrosinekinasedomain(codons835 or 836 of the second tyrosinekinasedomain)arenoted in 5 8 % of AML, but are rarein MDS (Bacheret al., 2007). Recurringtranslocationsinvolving the MLL gene at I lq23 are uncommon in MDS; however,a partialtandemduplicationof exons 3-9.3-1 0, or 3- 1 1 hasbeen reportedin MDS (3%) and in a higher percentagein cases of AML arising from MDS (7%) (Bacher et al., 2007). The MLL protein is a histone methyltransferasethat assembles in protein

Mutatedin 1 4 % of MDS, higher in CMML (10-20%) Mutatedin L2-20%, increasedwith higher risk MDS

CEBPA

Internaltandem duplication(ITD)in -10% of MDS and AML with mlineage dysplasia

Point mutationsidentified

Overrepresentation in MDS of RA subtype(36% versus 2 I % in normal blood donors)

FLT3

GCSFRG

HLA-DRIS (DRZ)

CSFIWFMS

Overexpressedin all FAB subtypes

BCL2

~

Alteration

Gene

~~

~~

Encodes a proteinproductthat suppressesapoptosis No correlationwith survival Highest levels noted in higherrisk entities where apoptosisis reduced Encodesa transcription factorthatis essentialforgranulopoiesis Mutationsappearto haveno effect on timeto overallprogression or overall survival Encodes the macrophagecolony-stimulatingfactorreceptor with tyrosinekinase activity Karyotypepredominantlyn o d Increasedfrequencyof transformationto AML andpoorsurvival Encodesa class II1 receptortyrosinekinaseinvolvedin cytokine signalingand stem cell differentiation ITD resultsin constitutiveactivationof protein Associatedwith progressionto AML and poor prognosis Frequentlyobservedwith a normalkaryotypein AML Encodes the G-CSF receptor Severe congenitalneutropenia(SCN) patientswith G-CSF receptordefects can progressto MDS andor AML Mutationalone is not sufficientfor transformation Progressionto leukemiain SCN associatedwith loss of chromosome7 and NRASKRAS mutations T-cell mediatedautoimmunemechanismimplicatedin some forms of MDS Correlatedwith responseto immunosuppressionof carefully definedMDS

AssociatedFeatures

TABLE 6.5 Genes Altered in the Myelodysplastic Syndromes

(continued)

Saunthararajah et al., 2002

Tidow et al., 1998

Horiikeet al., 1997; Kiyoi et al., 1998; Bacher et al., 2007

Ridge et al., 1990; Padua et al., 1998

Shih et al., 2005

Lepelley et al., 1995; Hayes et al., 1997; Parkeret al.. 2000

References

MPL

MU

MDM2

MDRI

KIT

Encodes a tyrosinekinase componentof variouscytokine signaling pathways Activating mutationsresult in constitutive signaling Mutationin 60%of patients with FURS with thrombocytosis,an unclassified MDSMPD Encodes the stem cell factor receptor Overexpressed;rare mutationsin MDS, KITD816 May provide an autocrinegrowth pathway Encodes a transmembranedrug efflux pump Expressed in -60% May be involved in resistanceof MDS to drug therapy Associated with monosomy 7 Encodes a proteinproduct(murinedouble minute-2)thatabrogates Overexpressedin -70% the function of the TP53 tumor suppressorprotein via ubiquitinationand degradationof TP53 Gene amplificationnot detected Associated with unfavorablecytogenetic abnormalities Shorterremission duration Encodes a histone methyltransferasethat assembles in protein Internaltandem complexes that regulategene transcriptionvia chromatin duplicationin 3% of MDS remodeling Increasedmutationfrequencyin AML following MDS Encodes the thrombopoietinreceptor Overexpressedin -45% of Higherexpression in RAEB and W E B - t associated with poor CMML, and -40% of prognosis, increasedprogression to AML W E B , RAEB-t patients; Correlatedwith dysmegakaryocytopoiesis underexpressed(-50% of normallevels) in most MDS patients, especially RA

Mutatedin 2-5% of MDS

JAK2v6'7F

Associated Features

Alteration

Gene

TABLE 6.5 (Continued)

Bouscary et al., 1995; Ogata and Tamura,2000

Bacher et al.. 2007

Bueso-Ramos et al., 1995; Fader1et al., 2000

Arland et al., 1994; Siitonen et al.. 1994 Zochbaueret al., 1994

Zippereret al., 2008

References

Mutationsrarein MDS, 5%in t-MDS

Mutatedin 10-15%; overexpressedin RA, RARS

Decreased expression via gene silencing by DNA methylation in 68%oftMDS/t-AML Somatic missense mutationsin 33% of JMMLpatients

Mutatedin 10-15 % MDS, 15-30% t-MDS

NPMl

NRAS

CDKN2B/p15"K4B

RUNXl/AMLI

PTPNll

Loss and mutations identified,particularlyin pediatric MDS/MPS

NFI

A nonreceptortyrosine phosphatasethat relays signals from activatedgrowth factor receptorsto RAS proteins Mutationsof NRAWkXAS, N F l , and PTPNl I are mutually exclusive Encodesthe DNA bindingsubunitof the heterodimericcorebinding factor (CBF) complex, which is essential for definitive hematopoiesis

Encodes neurofibromin,a tumor suppressorgene product,that functionsas a GTPase-activating(GAP) proteinto downregulate RAS function High incidence of MDS and AML in children with neurofibromatosistype I No structuralalterationin homologous allele in adultswith loss of one chromosome 17 Encodes a protein with diverse functions in the cell, including chromatinremodeling, genome stability, ribosome biogenesis, DNA duplication, and transcriptionalregulation Mutationstypically involve exon 12, resulting in C-terminus alterations,and aberrantprotein localization to the cytoplasm Encodes a GTPase componentof various cytokine signal transductionpathways Activating mutationsresult in constitutive signaling Associated with monocytic component Increasedrisk of progressionto AML Overexpressionmay representan early event in the multistep process of transformation Associated with -7/de1(7q) Closely associated with deletion or loss of 7q Independentlyassociated with poor survival

(continued)

Niimi et al., 2006; Chen et al., 2007

Lob et al., 2004

Christiansenet al., 2003

Paduaet al., 1998; Bacher et al., 2007

Pedersen-Bjergaard et al., 2007

Shannonet al., 1994; Gallagheret al., 1997

d

8

Alteration

Increasedactivity late in disease, particularlyTERT

Mutatedin 5-25%; higher frequency in t-MDS

Associated with overexpression

Telomerase(including TERT, TR, and TPI)

TP53

WTl

~

Gene

TABLE 6.5 (Continued) Point mutationsin the Runt (DNA binding) domain result in loss of function and a dominantnegative effect Associated with activatingmutationsof the RAS pathway, -7/del (7q), and a shorteroverall survival Enzyme complex responsible for chromosometelomere maintenanceand replication Variablelevels of activity Abnormaltelomere maintenancemay be an early indicationof genetic instability Telomeres shortenedwith disease progression Encodes G1, S, andG2 checkpointproteinproduct,which monitors integrityof genome;arrestscell cycle in responseto DNA damage Loss of wild-type allele Associated with weak BCL2 expression Observed as both early and late genetic event in MDS Associated with rapid progression and poor outcome Seen with loss of 17p, -5/de1(5q), suggesting pathogenic exposure to carcinogens Significantly differentiatesworse prognosis within each IPSS subgroup Overexpressedin 6 5 8 of bone marrowspecimens and 78% of peripheralblood specimens overexpressed comparedto normal cells, including all RAEB and t-AML patient samples Correlatedwith blast counts and cytogenetic abnormalities Significantly correlatedwith IPSS score

Associated Features

Cilloni and Saglio, 2004

h4isawaandHoriike, 1996; Christiansenet al., 2001; Kita-Sasai et al., 2001

Counteret al., 1995; Norrbackand Roos, 1997; Xu et al., 1998; Li et al., 2000

References

ALTERATIONS IN GENE FUNCTION

163

complexes that regulategene transcriptionvia chromatinremodeling.Targetgenes of the MLL transcriptionalregulatorycomplexes include the HOX genes, which have a critical role in developmentas well as hematopoiesis. The Runt-relatedtranscriptionfactor1 (RUNXl)gene, also knownasAML1,encodesthe DNA binding subunitof the heterodimericcore binding factor (CBF)complex, which is essentialfor definitivehematopoiesis.Point mutationsin the RUNXl Runt(DNA binding) domainhave been reportedin AML and MDS (1 2%), particularlyin MDS secondaryto atomicbomb radiationexposureor treatmentwith cytotoxictherapy,andincreasewith the seventy of the disease. Moreover, R U M 1 mutations are associated with activating mutations of the RAS pathway, -7/de1(7q), and a shorter overall survival (Niimi et al., 2006; Chen et al., 2007). Mutationsof NPMl also occur frequentlyin AML (35% of adultcases), but are less frequent in patients with recurringcytogenetic abnormalities.In the absence of FLT3 mutations,NPMZ mutationsareassociatedwith a favorableprognosis(Faliniet al., 2005). NPMl mutations most commonly involve exon 12, resulting in alterationsat the Cterminus,that is, replacementof tryptophan(s)at position 288 and 290 and creationof a nuclearexportsignal(NES)motif whichmediatesaberrantlocalizationof the proteinto the cytoplasm.Few studieshaveexaminedNPMl mutationsin MDS; however,mutationshave been reportedin rarecases of MDS andin -5% of patientswith t-MDS(Pedersen-Bjergaard et al., 2007). Of note, the NPMl gene locatedat 5q35 is not mutatedin MDS with a del(5q) (Shiseki et al., 2007). In AML, mutationsof the CCAATIenhancerbindingprotein-alphatranscriptionfactor gene (CEPBA) are often biallelic and are generallyassociatedwith a favorableprognosis. CEBPA mutationsoccur in 6-1 5%of AML de novo and in 15-1 8%of AML with a normal karyotype(Leroy et al., 2005). Althoughmutationsmay occur throughoutthe gene, two generalcategoriesof mutationsoccur:(1) out-of-frameinsertionsand deletions in the Nterminalregion, which result in a truncateddominant-negative30 kDa proteinthat lacks transactivationactivity,and (2) in-frameinsertionsanddeletionsin the C-terminalregion. Similarmutationshave been identifiedin MDS, rangingin frequencyfrom0 to 8%of cases. In MDS, CEBPA mutationsare seen at the highest frequencyin CMML (15-20%), and mutationsmay occur either as an early or late event in the course of the disease (Shih et al., 2005). In this small series, CEBPA mutationshad no effect on time to AML progressionor overall survival. TheTP53 tumorsuppressorgeneencodesanessentialcheckpointproteinthatmonitorsthe integrityof the genome and arrestscell cycle progressionin response to DNA damage. Mutationsof TP53 areobservedin primaryMDS (5-10%) and,morecommonly,in t-MDS (25-30%) (Christiansenet al., 2001; Kita-Sasai et al., 2001). The spectrumof mutations includesmissensemutationsin exons4-8 as well as loss of the wild-typeallele,typicallyas a resultof a cytogeneticabnormalityof 17p.TP53 mutationsmay occuras eitheranearlyorlate event in the course of the disease, and are associated with rapid progressionand a poor outcome.Int-MDS,TP53 mutationsareassociatedwith -5/de1(5q) anda complexkaryotype. The identificationof JAK2 mutations(JAK2v6’7F) in polycythemiaVera (90-95%). essentialthrombocytosis(50-70%), and myelofibrosis(40-50%) representsan important advancein our understandingof the MPDs. JAK2v6’7F is a constitutivelyactive tyrosine kinasethatis able to activateJAK-STATsignalingmost efficiently when coexpressedwith the erythropoietinreceptor, thrombopoietinreceptor (MPL), or the G-CSF receptor. JAK2v6’7F has also been identified in rare cases of MDS (2-5%) and CMML (3%) (Steensmaet al., 2005). An exception is refractoryanemiawith ringed sideroblastswith

164

MYELODYSPLASTIC SYNDROMES

thrombocytosis(RARS-t),a myelodysplastic/myeloproliferative syndromeunclassifiedby the WHOclassification,in which 60%of patientshave the JAK2v6'7F mutation(Zipperer et al., 2008). RARS-t patientswith JAK2V6'7Fmutationspresent with higher WBC and plateletcounts. The role of epigeneticchanges in the pathogenesisand treatmentof MDS is becoming increasinglyimportant.Transcriptionalsilencing via DNA methylationof the CDKN2B gene is observedin a high percentageof patientswith t-MDS and is associated with -7/de1(7q) anda poorprognosis(Christiansenet al., 2003). Moreover,thefrequencyof CDKN2B methylationincreaseswith progressionfrom RA to WEB-T. Othergenes that may be affected by DNA methylationinclude CTNNAl on 5q.

GENETIC PATHWAYS LEADING TO MDS Extensiveexperimentalevidence indicatesthat morethanone mutationis requiredfor the pathogenesisof hematologicalmalignantdiseases (Alcalay et al., 2001 ;Kelly and Gilliland, 2002). That is, expression of translocation-specificfusion genes or deregulated expressionof oncogenes is required,but insufficientby itself to induce leukemia.Thus, an importantaspectof leukemiabiology is the elucidationof the spectrumof chromosomal abnormalitiesand molecularmutationsthat cooperatein the pathwaysleading to leukemogenesis (Pedersen-Bjergaard et al., 2002). There is growing evidence that a limited numberof molecularpathwaysmay be involved. Kelly andGilliland(2002) havedescribed an emergingparadigmin AML, namely,the cooperationbetween constitutivelyactivated tyrosinekinase molecules, such as FLT3, and transcriptionfactorfusion proteins.In this model, the activated tyrosine kinase (Class I mutation) confers a proliferativeand/or antiapoptoticactivity, whereas the fusion protein (Class I1 mutation) impairs normal differentiation pathwaysbut has a limited effect on cellular proliferation.The existing evidence suggests that this model is also applicableto MDS. As describedin the previoussection, activatingmutationsof oncogenesandinactivating mutationsof tumorsuppressorgenes have been identifiedin a numberof loci in MDS and AML andmay occur in conjunctionwith recurringchromosomalabnormalities.In general, mutationof multipleClass I genes (or Class I1 genes) is mutuallyexclusive;however,there is cooperationbetween Class I and Class 11 mutations.For example, -7/de1(7q) has been associated with activatingmutationsof the RAS pathway (activatingKRAS, NRAS, or PTPNI I mutationsor inactivatingmutationsof N F I ) and RUNXl mutations,as well as gene (Christiansenet al., 2003; Loh methylationsilencing of the CDKN2B et al., 2004; Side et al., 2004). TP53 mutationsare uncommonin this subgroup.In contrast, MDS associated with -5/de1(5q) is associated with TP53 mutations and a complex karyotype(Christiansenet al., 2001; Side et al.. 2004). With respectto the t( 1 1;16) observed in a small subset of t-MDS patients,overexpressionof the FLT3 gene is characteristicof MLL-associatedleukemias(Armstronget al., 2002). Although our understandingof the associationof chromosomalabnormalitieswith gene mutationsin MDS remainsincomplete,severalpatternsof cooperatingmutationshavenow emerged,suggestingthatthereare multiplegenetic pathwaysleading to MDS. Gene expressionprofilingof MDS andt-MDS has also providedsupportfor the concept of distinctmolecularand genetic subsetsof MDS. Using expressionprofilingof CD34 cells in t-MDS and t-AML,Qian et al. (2002) found thatpatientswith a -5/de1(5q) had a higher expression of genes involved in cell cycle control (CCNA2, CCNE2, CDC2). +

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165

checkpoints (BUBf), or growth (MYC), but loss of expression of the gene encoding interferonconsensus sequence binding protein (ICSBPBRF8). A second subgroupof tAML, includingpatientswith -7/de1(7q), was characterizedby downregulationof transcriptionfactors involved in early hematopoiesis(TAL1, GATA1, and EKLF)but overexpressionof proteinsinvolved in signaling pathwaysin myeloid cells (FLT3) and cell survival(BCL2). Similarly, expression profiling of CD34+ cells from patients with primary MDS revealed that the expression profile of 11 selected genes could accuratelydistinguish low-riskfromhigh-riskMDS cases (Hofmannet al., 2002; Pellagattiet al., 2006). Pellagatti et al. (2006) performedexpressionprofilinganalysisof 55 patientswith primary MDS and identifieda numberof genes thatwere differentiallyexpressedin CD34+ cells fromMDS patientsversushealthycontrols.The mosthighly representedgene categoryin both up- and downregulatedgenes were genes involved in signaltransduction.The expressionprofilein M D S revealed many similaritiesto the patternobserved in interferon-gamma stimulated normalCD34 cells. Indeed,the two most upregulatedgenes wereIFITl andIFflMI, both interferon-stimulated genes.Withrespectto specificsubsets,cells frompatientswith RARS had a unique expression profile characterizedby upregulationof mitochondria-related genesandgenes involvedin heme synthesis,forexample,ALAS2. Interestingly,hierarchical clusteringseparatedMDS patientswith a del(5q) from those with a normalkaryotypeor other abnormalities.Genes that were differentiallyoverexpressedin cells with a del(5q) included a numberof the histone genes within the HZSTl cluster,genes encoding actinbinding or myosin-relatedproteins, includingARPC2, COROl C, MYL6, CAPZ42, and WASPIP, as well as megakaryocyte/platelet-associatedgenes, includingPF4VZ, PPBP, THBSI, GPIBA, and CD61. Notably,numerousgenes mappingto 5q were underexpressed. In other studies, the same investigatorsdemonstratedthat CD34+ cells from patients with the 5q- syndromealso had a distinct expressionprofile (Boultwood et al., 2007; Pellagattiet al., 2006). A reductionin the expressionlevel of severalgenes mappingwithin the CDS was consistent with haploinsufficiency,such as SPARC, RPS14, RMB22, and CSNKfAl.Pathwayanalysisrevealedderegulationof the Wnt/p-cateninpathway,a critical regulatorof hematopoieticstem cells, as well as the proteinubiquitinationpathway. In a similarstudy,global expressionprofilingof the stem cell populationin the 5q- syndrome suggestedthatthe disease arisesin CD34 CD38-Thy 1 stemcells (Nilssonet al., 2007). Expressionof BMZZ, encoding a criticalregulatorof self-renewal,was upregulatedin del (5q) stemcells, whereasthe CEBPA myeloidtranscriptionfactorgene was downregulated. Establishingthe molecularpathwaysinvolved in MDS may facilitatethe identificationof selectively expressedgenes that can be exploited for the developmentof urgentlyneeded targetedtherapies. At present, there are a number of unansweredquestions regarding the molecular pathogenesisof MDS. For example, we do not yet know the full spectrumof genetic mutationsin MDS withineach pathway,nordo we know the orderin which thesemutations occur,andthe prognosticsignificanceassociatedwithmanycooperatingmutations.Several possiblemodelsareoutlinedin Fig. 6.6. Manypieces of experimentalevidencesuggestthat the recurringchromosomalabnormalitiesin MDS and AML are likely to be the initiating event.Withrespectto the recurringtranslocations,the rearrangement is likely to occurin a hematopoieticprogenitorcell or, in some cases, in a committedmyeloid progenitorcell. Leukemogenesismay entail a linear process in which the initiatingmutationleads to a specificpatternof stepwise, additionalmutationsthatcompletemalignanttransformation. In MDS, the process may vary somewhat in that the initiatingmutationsmay occur in a +

+

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Pathways to MDS and AML

22" Oq;,-+@ proteins

+ + + + NMRAS, FLl3-l7DS KIT,

OI NPMl

CMP

AML

-TPs3 - . complex *+++ +

persists

MDSlAML

FIGURE6.6 Models for the genetic pathwaysleadingto MDS. See text for a discussionof the alternativemodels. In the lower panel, the examplesof the -5/de1(5q) and -7/de1(7q) are used to illustratethe models of MDS arisingin the settingof a normalbone marrowenvironmentversusan abnormalbone marrow environment,respectively.It is possible thateitherabnormalitycan arise in both settings,and that each model may occur.

hematopoieticstem cell. In the setting of a normalbone marrowmicroenvironment,the initiatingmutationmay resultin clonalexpansioncoupledwith emerginggeneticinstability (orthe selectionof cooperatingmutationsthatlead to instability),andthe developmentof a clonal population. Selective pressures created both by the microenvironmentand the initiatingeventswould lead to the acquisitionof additionalmutationsnecessaryto complete malignanttransformation. Alternatively,MDS may arisein the settingof an abnormalbone marrowmicroenvironment, resultingin the generationof multiplepopulationswith varying initiatingevents. Some clonal populationsmay persist, whereasothersmay undergocell death, and yet others may go on to acquireadditionalmutationsnecessary to complete malignanttransformation. The lattermodel would accountfor the observationof unrelated cytogenetic clones in the bone marrow of MDS patients as well as the observationof persistentdysplasiain MDS or AML patientsfollowing therapy.Emergingtechnologies, such as the ability to culture stromal cell populations,and proteomics and genomics technologies may facilitatethe evaluationof these variousmodels.

EMERGING TECHNOLOGIES Recent advances in microarraytechnology have enabled high-resolutiongenome-wide genotypingusing single nucleotidepolymorphisms.This technology facilitatesgenomewide associationstudies for the identificationof disease susceptibilityloci as well as the identificationof acquiredabnormalities,such as genetic imbalances,for example,cryptic deletionsand duplications.A majoradvantageof this technology is the ability to identify LOH that occurs without concurrentchanges in the gene copy number,which can be attributedto somatic mitotic recombination(referredto as copy-neutralLOH). Several recentstudies have validatedthe diagnosticutilityof this technology in MDS. Using 50 K arrays(50,000 S N P arrays,confirmedwith 250 K and 500 K arrays)to examineDNA from

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bone marrowcells of patientswith low-risk MDS (RA, RARS, RCMD, RCMD-RS, and RAEB;n = 1 19), Mohamedaliet al. (2007) identifiedcopy-neutralLOH in 46%,deletions in lo%, and amplificationsin 8%of cases (note, the authorsconcludedthat copy-neutral LOH may be constitutional).The most frequent abnormalitywas copy-neutralLOH involving 4q, observed in 25% of RARS, 12% of RCMD with a normal cytogenetic pattern, 17% of RAEB, and 6% of the 5q- syndrome.Copy numberaberrationswere indicativeof a poor prognosis. Gondeket al. (2008) extended these observationsusing 250 K arraysto examine 174 patients(94 MDS; 33 AML following MDS; 47 MDSMPD); theresultswerevalidatedby the microarrayanalysis of germlineDNA as well as quantitativePCR analysis. Acquired copy-neutralLOHwas identifiedin 20%of MDS, 23%of AML following MDS, and35% of MDS/MPD (particularlyCMML). Collectively,abnormalitiesweredetectedin a higher proportionof cases thanby conventionalcytogeneticanalysis(78%versus59%for MDS). New lesions detected by microarrayanalysis includedcopy-neutralLOH of 6p2 1.2-pter, 1 1q 13.5-qter,4q23-qter,7q 11.23-qter,and7q22.1. With respectto the prognosticvalueof SNParrays,patientswith a normalkaryotypein whom new lesions were detectedby SNP arrayanalysis had a reducedoverall survival (1 6 monthsversus 39 months) than those without new lesions. When the presence of newly identified SNP array lesions were factoredinto the IPSS classification,the survivalcurves divergedfor patientsoriginally classified as IPSS Intermediate-1, suggesting that SNP arraysprovide additionalinformation allowing for better prognostic resolution (median survival 28 months versus 9 months,p = 0.03). Thus,the resultsof these studiessuggest thatSNP arrayanalysismay have futurediagnosticapplicationand may complementchromosomebandingcytogenetic analysis in risk stratificationand the selection of therapy.

SUMMARY The role of cytogenetic analysis in MDS remains a pivotal element for establishingthe diagnosis, prognosis, and therapeuticplan, including the initiation of specific targeted treatmentsand the follow-up of altered clinical behavior of the disease. The recurring abnormalities,althoughrarelyspecificfora diseaseentity,havenot only providedinsightinto prognosisbutalsointothe molecularpathogenesisof theseheterogeneousdisorders.Coupling carefulclinical observationwith both classical cytogenetictechniquesand newer genomic technologieswill refine our understandingof these often unpredictablemyeloid diseases.

REFERENCES Abe A, Emi N, TanimotoM, TerasakiH, MarunouchiT, SaitoH (1997):Fusionof theplatelet-derived growthfactorreceptorbeta to a novel gene CEV14 in acute myelogenousleukemiaafterclonal

evolution.Blood 90:427 1-4277. Adeyinka A, Dewald GW (2003):Cytogeneticsof chronicmyeloproliferativedisordersand related rnyelodysplasticsyndromes.Hematol Oncol Clin North Am 17: 1 129- I 149. Alcalay M, OrlethA, SebastianiC, Meani N. ChiaradonnaF,CasciariC, SciurpiMT, GelmettiV, Riganelli D, Minucci S, Fagioli M, Pellicci PG (2001): Commonthemesin the pathogenesisof acute myeloid leukemia.Oncogene 205680-5694.

168

MYELODYSPLASTICSYNDROMES

Apperley JF, GardembasM, Melo JV, Russell-Jones R, Bain BJ, Baxter EJ, Chase A, Chessells JM, Colombat M, Dearden CE, Dimitrijevic S, Mahon FX, Marin D, Nikolova Z, Olavania E, Silberman S, Schultheis B, Cross NC, Goldman JM (2002): Response to imatinib rnesylatein patients with chronic myeloproliferative diseases with rearrangementsof the platelet-derived growth factor receptorbeta. N Engl J Med 347:48 1487. ArlandM, FiedlerW,SamalecosA, HossfeldDK (1994): Absence of pointmutationsin a functionally importantpartof the extracellulardomainof the c-kit proto-oncogene in a series of patientswith acute myeloid leukemia (AML). Leukemiu 8:498-501. ArmstrongSA, StauntonJE, SilvermanLB, Pieters R, MindenMD, Sallan SE, LanderES, GolubTR, KorsmeyerSJ (2002): MLL translocationspecify a distinct gene expression profile that distinguishes a unique leukemia. Nat Genet 30:41-47. Aul C, Bowen DT, Yoshida Y (1998): Pathogenesis. etiology and epidemiology of rnyelodysplastic syndromes. Haematologica 83:7 1-86. BacherU,HaferlachT, KernW, HaferlachC, SchnittgerS (2007): A comparativestudy of molecular mutationsin 381 patientswith myelodysplasticsyndromeand in 4 130 patientswith acute myeloid leukemia. Haematologica 92:744-752. Bain BJ, Moorman AV, Johansson B, Mehta AB, Secker-Walker LM (1998): Myelodysplastic syndromes associated with 1 1 q23 abnormalities.Leukemia 12:834839. Beaupre DM, Kurzrock R (1999): RAS and leukemia: from basic mechanisms to gene-directed therapy.J Clin Oncol 17:1071-1079. Bench AJ, Nacheva EP, Hood TL, HoldenJL,FrenchL, SwantonS, ChampionKM, Li J, WhittakerP, Stavrides G, Hunt AR, Huntly BJ, Campbell LJ, Bentley DR, Deloukas P, Green AR (2000): Chromosome 20 deletions in myeloid malignancies: reduction of the common deleted region, generationof a PAClBACcontig and identificationof candidategenes. UK CancerCytogenetics Group (UKCCG). Oncogene 19:3902-3913. BennettJM,CatovskyD, Daniel MT,FlandrinG, GaltonDA, GralnickHR, SultanC (1982): Proposals for the classification of the myelodysplasticsyndromes.Br J Huematol51: 189-199. Bjork J, Albin M, Mauritzson N, Stromberg U, Johansson 3, Hagmar L (2000): Smoking and myelodysplastic syndromes. Epidemiology 1 I :285-291. BlockAW,Carrollkl,HagemeijerA,MichauxL,vanLomK,OlneyHJ, BaerMR(2002):Rarerecumng balanced chromosome abnormalities in therapy-related myelodysplastic syndromes and acute leukemia:reportfrom an internationalworkshop. Genes Chromosomes Cancer 33:40 1-412. BloomfieldCD, ArcherKJ, MrozekK, Lillington DM, KanekoY,Head DR, Dal Cin P, RaimondiSC (2002): 1 1 q23 balancedchromosomeaberrationsin treatment-relatedmyelodysplasticsyndromes and acute leukemia: report from an international workshop. Genes Chromosomes Cancer 33:362-378. Boultwood J, Lewis S, WainscoatJS (1994): The 5q- syndrome. Blood 84:3253-3260. BoultwoodJ, FidlerC, StricksonAJ, WatkinsF, Gama S, KearneyL, Tosi S, KasprzykA, ChengJF, JajuRJ, WainscoatJS (2002): Narrowingandgenomic annotationof the commonly deletedregion of the 5q- syndrome.Blood 99:4638-4641. Boultwood J, Pellagatti A, Cattan H,Lawrie CH, Giagounidis A, Malcovati L, Della Porta MG, JaderstenM, Killick S, Fidler C, Cazzola M, Hellstom-LindbergE, WainscoatJS (2007): Gene expression profiling of CD34+ cells in patients with the 5q- syndrome. Br J Haematol 139578-589. BouscaryD, PreudhommeC, RibragV,Melle J,Viguie F, PicardF, GuesnuM,FenauxP,Gisselbrecht S, Dreyfus F (1 995): Prognostic value of c-mpl expression in myelodysplastic syndromes. Leukemia 9:783-788. Bowen D, Culligan D, Jowitt S, Kelsey S, Mufti G, Oscier D, ParkerJ (2003): Guidelines for the diagnosis and therapyof adult myelodysplastic syndromes. Br J Haemutol 120:187-200.

REFERENCES

169

Bueso-RamosCE, ManshouriT, HaidarMA, Huh YO, Keating MJ, Albitar M (1995): Multiple patternsof MDM-2 deregulationin human leukemias: implications in leukemogenesis and prognosis.Leuk Lymphoma 17:13-1 8. CazzolaM, MalcovatiL (2005): Myelodysplasticsyndromes:coping with ineffectivehematopoiesis. N Engl J Med 352536538. ChenCY, Lin LI, TangJL, KOBS, Tsay W, Chou WC, Yao M, Wu SJ, Tseng MH, Tien HF (2007): RUNX I gene mutationin primarymyelodysplasticsyndrome:the mutationcanbe detectedearlyat diagnosis or acquiredduring disease progressionand is associated with poor outcome. Br J Harniatol 139:405-414. ChristiansenDH, AndersenMK, Pedersen-Bjergaard J (200 1 ): Mutationswith loss of heterozygosity of p53 arecommonin therapy-relatedmyelodysplasiaandacutemyeloid leukemiaafterexposure to alkylatingagentsand significantlyassociatedwith deletionor loss of 5q, a complexkaryotype, and a poor prognosis.J Clin Oncol 19:1405-1413. J (2003):Methylationof pl51NK4Bis common, ChristiansenDH, AndersenMK,Pedersen-Bjergaard is associated with deletion of genes on chromosomearm 7q and predictsa poor prognosisin therapy-relatedmyelodysplasiaand acute myeloid leukemia.Leukemia 17:1813-18 19. Cilloni D, Saglio C (2004): WT1 as a universalmarkerfor minimal residualdisease detectionand quantificationin myeloidleukemiasandin myelodysplasticsyndrome.Acta Huematoll 1279-84. CounterCM. Gupta J, Harley CB, Leber B, Bacchetti S (1995): Telomeraseactivity in normal leukocytesand in hematologic malignancies.Blood 85:2315-2320. CurtissNP, BonifasJM, LauchleJO,BalkmanJD,KratzCP,EmerlingBM, GreenED, LE Beau MM, ShannonK M (2005): Isolationand analysisof candidatemyeloid tumorsuppressorgenes from a commonly deleted segment of 7q22. Genomics 85:600407. de Souza Femandez T, Menezes de Souza J, Macedo Silva ML, Tab& D, Abdelhay E (1998): Correlationof N-ras point mutations with specific chromosomal abnormalitiesin primary myelodysplasticsyndrome.k u k Res 22: 125-1 34. de Souza FernandezT, OrnellasMH, Oterode CarvalhoL, Tab& D, AbdelhayE (2000): Chromosomal alterationsassociated with evolution from myelodysplasticsyndrometo acute myeloid leukemia.Leuk Res 24339-848. Dewald GW, PierreRV, Phyliky RL (1982): Three patientswith structurallyabnormalX chromosomes, each with Xq 13 breakpointsand a history of idiopathicacquiredsideroblasticanemia. Blood 59: 100-105. DiihnerK,BrownJ, HehmannU, HetzelC, StewartJ, LowtherG, SchollC, FriihiingS, CuneoA, Tsui LC, LichterP, SchererSW, DohnerH ( I 998): Molecularcytogeneticcharacterization of a critical region in bands7q35-36 commonlydeletedin malignantmyeloiddisorders.Blood92403 14035. DiihnerK, HabdankM,RuckerFG, MillerS, FrolingS, SchererSW,BullingerL. DohnerH (2006): Molecularcharacterizationof distincthot spot regionson chromosome7q in myeloid leukemias. Blood 108:2349. EbertBL, PretzJ,Bosco J, ChangCY, TamayoP, GaliliN, RazaA, Root DE, AttarE, Ellis SR, Golub TR (2008):Identificationof R B I 4 as a 5q- syndromegene by RNA interferencescreen.Nature 45 1 :335-339. EmanuelPD ( 1999): Myelodysplasiaand myeloproliferativedisordersin childhood:an update.Br J Haematol l05:852-863. Fader1S, KantajianHM, EsteyE, ManshouriT,ChanCY, RahmanElsaiedA, KornblauSM, CortesJ, ThomasDA, PierceS, KeatingMJ,EstrovZ, AlbitarM (2000): The prognosticsignificanceof p16 (INK4a)/pl4(ARF)locus deletion and MDM-2 proteinexpressionin adult acute myelogenous leukemia. Cancer 89:1976--1982. FairmanJ, ChumakovI, ChinaultAC, Nowell PC,NagarajanL (1995): Physical mappingof the minimalregion of loss in 5q- chromosome.Proc Natl Acad Sci USA 92:7406-7410.

170

MYELODYSPLASTIC SYNDROMES

FaliniB, MecucciC, TiacciE, AlcalayM,RosatiR, PasqualucciL, La StarzaR, DiverioD, Colombo E, SantucciA, BigernaB, PaciniR, PucciariniA, Liso A, VignettiM, FaziP, MeaniN, PettirossiV, F, Pelicci PG, MartelliMF, GIMEMAAcute LeukemiaWorking Saglio G, MandelliF, Lo-COCO Party(2005): Cytoplasmicnucleophosminin acutemyelogenousleukemiawith a normalkaryotype. N Engl J Med 352:254-266. FenauxP, LucidarmeD, Lai JL, BautersF ( 1989): Favorablecytogeneticabnormalitiesin secondary leukemia.Cancer 63:2505-2508. FeroML,RivkinM, TaschM,PorterP, CarowCE,FirpoE, PolyakK, TsaiLH,BroudyV, PerlmutterRM, KaushanskyK, Roberts JM (1996): A syndrome of multiorganhyperplasiawith features of gigantism,tumorigenesis,and female sterilityin p27(Kip1)-deficientmice. Cell 85:733-744. FischerK,FrohlingS, SchererSW,McAllisterBrownJ, Scholl C, StilgenbauerS, Tsui Us,LichterP, Dohner H ( 1997): Molecularcytogeneticdelineationof deletions and translocationsinvolving chromosomeband 7q22 in myeloid leukemias.Blood 89:2036-2O41, FrenchJE, LacksGD, TrempusC, DunnickJK,Foley J, MahlerJ, "ice RR,TennantRW (2001): Loss of heterozygosityfrequencyat the Trp53locus in p53-deficient( + I - ) mouse tumorsis carcinogen- and tissue-dependent.Carcinogenesb 2299-106. GallagherA, Darley RL, Padua R (1997): The molecular basis of rnyelodysplasticsyndromes. Haematologica 82:191-204. Garcia-ManeroG, ShanJ, Fader1S, CortesJ,RavandiF, BorthakurG, WierdaWG, pierceS, Estey E, Liu J, HuangX, KantarjianH (2008): A prognosticscore for patientswith lower risk myelodysplastic syndrome.Leukemia 22:53&543. GeddesAA, Bowen DT, JacobsA (1990):Clonalkaryotypeabnormalitiesandclinicalprogressin the myelodysplasticsyndrome.Br J Haematol76: 194-202. Godley LA. Larson RA (2002): The syndrome of therapy-relatedmyelodysplasiaand myeloid leukemia. In: Bennett JM, editor. The Myelodysplastic Syndromes: Pathobiology and Clinical Management. New York: Marcel DekkerInc., pp 136176. GolubTR, BarkerGF, LovettM, GillilandDG (1994): Fusionof PDGFreceptorbetato a novel ETSlike gene, tel. in chronicmyelomonocyticleukemiawith t(5;12) chromosomaltranslocation.Cell 77~307-316. GondekLP,Tiu R, O'KeefeCL, SekeresMA, Theil KS, MaciejewskiJP(2008): Chromosomallesions and uniparentaldisomy detectedby SNP arraysin MDS, MDSMPD. and MDS-derived AML. Blood 1 11 :1534-1 542. Gozzetti A, Le Beau MM (2000): Fluorescencein situ hybridization:uses and limitations.Semin Hematol37:32&333. GreenbergP, Cox C, Le Beau MM,FenauxP, MorelP, SanzG, SanzM, VallespiT, HamblinT, Oscier D, OhyashikiK. ToyamaK, Aul C, Mufti G, BennettJ ( 1997): Internationalscoring system for evaluatingprognosis in myelodysplasticsyndromes.Blood 89:2079-2088. Groupe Francais de CytogenetiqueHematologique(199 1): Chronic myelomonocytic leukemia: single entityor heterogeneousdisorder?A prospectivemulticenterstudyof 100 patients.Cancer Genet Cytogenet 5557-65. HaaseD, GermingU, SchanzJ, PfeilstockerM, NosslingerT, HildebrandtB, KundgenA, LubbertM, KunzmannR, GiagounidisAA, Aul C, TriimperL, Krieger0, StauderR, MullerTH, WimazalF, ValentP, FonatschC, SteidleC (2007): New insightsintothe prognosticimpactof the karyotypein MDS and correlation with subtypes: evidence from a core dataset of 2124 patients. Blood 11043854395. HamblinTJ, Oscier DG (1987): The myelodysplasticsyndrome:a practicalguide. Hematol Oncol 5:19-34. Hasle H (2007): Myelodysplasticand rnyeloproliferativedisordersin children.Curr Opin fediatr 19: 1-8.

REFERENCES

171

Hayes RB, Yin SN, Dosemeci M, Li GL, WacholderS, Travis LB, Li CY, RothmanN, Hoover RN, Linet MS ( 1997): Benzene and the dose-related incidence of hematologic neoplasms in China. ChineseAcademyof PreventiveMedicine:NationalCancerInstituteBenzene StudyGroup.J Natl Cancer Inst 89:1065-107 1. HofmannWK, de Vos S, KomorM, Hoelzer D, WachsmanW, KoefflerHP (2002): Characterizationof gene expression of CD34+ cells from normal and myelodysplastic bone marrow. Blood 100:3553-3560. Horiike S , Taniwaki M, Misawa S, Abe T (1988): Chromosome abnormalitiesand karyotypic evolution in 83 patients with myelodysplastic syndrome and predictive value for prognosis. Cancer 62: 1129-1 138. Horiike S, YokotaS, Nakao M, Iwai T, Sasai Y,Kaneko H, TaniwakiM, Kashima K, Fuji H, Abe T, Misawa S (1997): Tandemduplicationsof the FLT3 receptorgene are associated with leukemic transformationof myelodysplasia. Leukemia 1 1:1442-1446. Homgan SK, ArbievaZH, Xie HY, KravarusicJ, Fulton NC, Naik H, Le 7T,WestbrookCA (2000): Delineationof a minimal intervaland identificationof 9 candidatesfor a tumorsuppressorgene in malignantmyeloid disorderson 5q31. Blood 95:2372-2377. Jaffe ES, HamsNL, Stein H, VardimanJW,editors(2001): WorldHealthOrganization Classification of Tumours.Pathology and Geneticsof Twnoursof Haematopoietic and Lymphoid Tissues.Lyon: ]ARC Press. JajuRJ, Boultwood.I Oliver , FJ, KostrzewaM, FidlerC, ParkerN, McPhersonJD, MorrisSW, Muller U, Wainscoat JS, Kearney L ( I 998): Molecular cytogenetic delineation of the critical deleted region in the 5q- syndrome.Genes Chromosomes Cancer 22:251-256. JaryL, Mossafa H, FourcadeC, Genet P, h l i k M,FlandrinG (1 997): The 17p- syndrome:a distinct myelodysplasticsyndrome entity? Leuk Lymphoma 25: 163-1 68. JohanssonB, Mertens F,Mitelman F (1993): Cytogenetic deletion maps of hematologic neoplasms: circumstantialevidence for tumor suppressorloci. Genes Chromosomes Cancer 8:205-218. JohnsonEl,SchererSW, OsborneL, TsuiLC, OscierD, MouldS, CotterFE (1996):Moleculardefinition of a narrowintervalat 7q22.1 associatedwith myelodysplasia.Blood 873579-3586. Joslin JM, Femald AA, TennantTR, Davis EM, Kogan SC, Anastasi J, CrispinoJD, Le Beau MM (2007): Haploinsufficiencyof EGRl, a candidategene in the del(5q), leads to the developmentof myeloid disorders.Blood 1 10:719-726. JotterandM, ParlierV ( 1996): Diagnostic andprognosticsignificanceof cytogenetics in adultprimary myelodysplastic syndromes. Leuk Lymphoma 23:253-266. KardosG, Baumann1, Passmore SJ, Locatelli F, Hasle H, Schultz KR, StaryJ, Schmitt-GraeffA, FischerA, HarbottJ, ChessellsJM, HannI, Fenu S, RajnoldiAC, KerndruG,Van Wenng E, Rogge T, Nollke P, Niemeyer CM (2003): Refractoryanemia in childhood:a retrospectiveanalysisof 67 patients with particularreference to monosomy 7. Blood 102:1997-2003. KearneyL ( 1999): The impact of the new fish technologies on the cytogenetics of haematological malignancies. Br J Haematol 104:648458. Kelly LM, Gilliland DG (2002): Genetics of myeloid leukemias. Annu Rev Genomics Hum Genet 3: 179-198. KereJ (1 989): Chromosome7 long arm deletion breakpointsin preleukemia:mappingby pulsed field gel electrophoresis.Nucleic Acids Res 17:1511-1520. Kita-SasaiY, HoriikeS, MisawaS, KanekoH, KobayashiM,NakaoM. NakagawaH, FujiiH, Taniwaki M (200 1): Internationalprognostic scoringsystem and TP53 mutationsare independentprognostic indicatorsfor patientswith myelodysplasticsyndrome.Br J Haematol 1 15:309-312. Kiyoi H, TowatariM, Yokota S, Hamaguchi M, Ohno R, Saito H, Naoe T (1998): Internaltandem duplicationof the FLY3gene is a novel modalityof elongation mutationwhich causes constitutive activation of the product.Leukemia 12:1333-1 337.

172

MYELODYSPLASTIC SYNDROMES

KnudsonAG Jr(1971): Mutationand cancer:statisticalstudyof retinoblastoma.ProcNatl AcadSci USA 68320-823. KratzCP, EmerlingBM,DonovanS , Laig-WebsterM. TaylorBR, ThompsonP, JensenS, BanejeeA, BonifasJ, MakalowskiW, GreenED. Le BeauMM,ShannonKM (2001): Candidategene isolation and comparativeanalysis of a commonly deleted segment of 7q22 implicated in myeloid malignancies.Genomics77: 171-180. KulkamiS , HeathC, ParkerS, ChaseA, IqbalS, Pocock CF, KaedaJ, CwynarskiK, GoldmanJM, Cross NC (2000): Fusion of H4/DlOS170 to the platelet-derivedgrowth factor receptorbeta in BCR-ABL-negative myeloproliferativedisorders with a t(5;10)(q33;q21). Cancer Res 60~3592-3598. Kurtin PJ, Dewald GW, Shields DJ, Hanson CA (1996): Hematologic disordersassociated with deletions of chromosome 20q: a clinicopathologicstudy of 107 patients.Am J Clin Pathol 106:680-688. KurzrockR, KantarjianHM, CortesJE,SinghaniaN, ThomasDA, Wilson EF,WrightJJ,FreireichEl, TalpazM, SebtiSM (2003): Famesyltransferase inhibitorR115777 in myelodysplasticsyndrome: clinical and biologic activities in the phase 1 setting. Blood 102:45274534. KussickSJ, FrommJR, Rossini A, Li Y,ChangA, NorwoodTH, Wood BL (2005): Four-colorRow cytometryshows strong concordancewith bone marrow morphology and cytogenetics in the evaluationfor myelodysplasia.Am J Clin Patholl24:170- I81. Lai JL, PreudhommeC, Zandecki M, Flactif M, VanrumbekeM, Lepelley P, WattelE, FenauxP (1995): Myelodysplasticsyndromesand acute myeloid leukemia with 17p deletion. An entity characterizedby specific dysgranulopoiesisand a high incidence of P53 mutations.Leukemia 9:370-381. Lai F, Godley LA, JoslinJ, FernaldAA, Liu J, EspinosaR 3rd,ZhaoN, PamintuanL, Till BG, Larson RA, Qian Z, Le Beau MM (2001): Transcriptmap and comparativeanalysis of the 1.5-Mb commonly deleted segment of human 5q31 in malignant myeloid diseases with a del(5q). Genomics 7 I :235-245. LarsonRA, LeBeau MM, VardimanJW, Rowley JD (1 996): Myeloid leukemiaafterhematotoxins. EnvironHealth Perspect 104: 1303-1307. Le Beau MM, AlbainKS, LarsonRA, VardimanJW, Davis EM, Blough RR, GolombHM, Rowley JD ( 1986):Clinicaland cytogeneticcorrelationsin 63 patientswith therapy-related myelodysplastic syndromesand acutenonlymphocyticleukemia:furtherevidencefor characteristicabnormalities of chromosomesno. 5 and 7. J Clin Oncol4:325-345. Le Beau MM,EspinosaR 3rd,NeumanWL, StockW, RoulstonD, LarsonRA, KeinanenM, Westbrook CA (1993): Cytogeneticand moleculardelineationof the smallestcommonly deleted region of chromosome5 in malignantmyeloid diseases. Proc Natl Acad Sci USA 905484-5488. Le Beau MM, EspinosaR 3rd, Davis EM, EisenbartJD, LarsonRA, GreenED (1996): Cytogenetic andmoleculardelineationof a regionof chromosome7 commonlydeleted in malignantmyeloid diseases. Blood 88: 1930-1 935. Lepelley P, Soenen V, PreudhommeC, MerlatA, Cosson A, Fenaux P (1995): bcl-2 expressionin myelodysplasticsyndromesand its correlationwith hematologicalfeatures,p53 mutationsand prognosis.Leukemia9:726-730. LeroyH, RoumierC, HuygheP,Biggio V, FenauxP, PreudhommeC (2005): CEBPApoint mutations in hematologicalmalignancies.Leukemia I9:329-334. Lewis S, AbrahamsonG, Boultwood J, Fidler C, Potter A, Wainscoat JS (1996): Molecular characterizationof the 7q deletion in myeloid disorders.Br J Haematol93:75-80. Li B, Yang J, Andrews C, Chen YX, ToofanfardP, Huang RW, HorvathE, ChopraH, Raza A, PreislerHD (2000): Telomeraseactivityin preleukemiaand acute myelogenousleukemia.Leuk Lymphoma36579-5 87.

REFERENCES

173

Liang H, FairmanJ , Claxton DF, Nowell PC, Green ED, NagarajanL (1998): Molecularanatomyof chromosome 7q deletions in myeloid neoplasms: evidence for multiple critical loci. froc Natl Acad Sci USA 95:3781-3785. List A, Dewald G, BennettJ, GiagounidisA, Raza A, FeldmanE, Powell B, GreenbergP, Thomas D. Stone R, ReederC, WrideK, PatinJ, SchmidtM, Zeldis J, KnightR, Myelodysplastic Syndrome003 StudyInvestigators(2006): Lenalidomidein the myelodysplasticsyndromewith chromosome 5q deletion. N Engl J Med 355:145&1465. Liu TX, Becker MW, JelinekJ. Wu WS, Deng M, MikhalkevichN, Hsu K, Bloomfield CD, StoneRM, DeAngelo DJ, Galinski IA, Issa JF', ClarkeMF, Look AT (2007): Chromosome5q deletion and epigenetic suppressionof the gene encoding alpha-catenin(CTNNA1 ) in myeloid cell transformation. Nut Med 13:78-83. Loh ML, VattikutiS, SchubbertS, Reynolds MG, CarlsonE, Lieuw KH, ChengJW, Lee CM, Stokoe D, Bonifas SM,Curtiss NP, Gotlib J, Meshinchi S, Le Beau MM, Emanuel PD, Shannon KM (2004): Mutations in FTPNII implicate the SHP-2 phosphatase in leukemogenesis. Blood 103~2325-2331. Look AT (1997): Oncogenic transcription factors in the human acute leukemias. Science 278:1059-1064. Luna-FinemanS, Shannon KM,Lange BJ (1995): Childhoodmonosomy 7: epidemiology, biology, and mechanistic implications. Blood 85:1985-1999. Ma X. Does M, RazaA, Mayne ST (2007): Myelodysplastic syndromes:incidenceand survival in the United States. Cancer 109:1536-1542. MacGroganD, KalakondaN, Alvarez S, ScanduraSM, Boccuni P, JohanssonB, Nimer SD (2004): Structuralintegrity and expression of the L3MBTLgene in normaland malignanthematopoietic cells. Genes Chromosomes Cancer 41 :203-213. Magnusson MK, Meade KE, Brown KE, ArthurDC, KruegerLA, BarrettAJ, DunbarCE (2001): Rabaptin-5is a novel fusion partnerto platelet-derivedgrowth factor beta receptor in chronic myelomonocytic leukemia. Blood 98:25 18-2525. Malcovati L, Genning U, Kuendgen A, Della PortaMG, PascuttoC, Invernizzi R, GiagounidisA, HildebrandtB, Bernasconi P, Knipp S, StruppC, LazzarinoM, Aul C, Cazzola M (2007): Timedependent prognostic scoring system for predicting survival and leukemic evolution in myelodysplastic syndromes. J Clin Oncol25:3503-35 10. MartinelliG,OttavianiE,Buonamici S, Isidori A, Borsaru G, Visani G, Piccaluga PP, Malagola M, TestoniN, RondoniM, NuciforaG,TuraS, BaccaraniM (2003): Association of 3q2 lq26 syndrome with different RPNlEVl I fusion transcripts.Haematologica 88:1221-1228. Martinez-ClimentJA, Garcia-Conde J ( 1999): Chromosomal rearrangementsin childhood acute myeloid leukemia and myelodysplasticsyndromes.J fediatr Hematol Oncol2 1:91-1 02. MaseratiE, Aprili F, VinanteF, Locatelli F, AmendolaG,ZatteraleA, Milone G, Minelli A, Bernadi F, Lo CurtoF, PasqualiF(2002): Trisomy8 in myelodysplasiaandacute leukemiais constitutionalin 6 2 0 % of cases. Genes Chromosomes Cancer 33:93-97. Mastrangelo R,Tomesello A, MastrangeloS, Zollino M, Neri G (1995): Constitution trisomy 8 mosaicism evolving to primarymyelodysplastic syndrome:a new subset of biologically related patients?Am J Hematol48:67-68. MatsudaA, YagasakiF, JinnaiI, KusumotoS, MurohasiI, Bessho M, HirashimaK (1998): Trisomy 8 may not be relatedto the pathogenesisof myelodysplasticsyndromes.Eur J Hemafo160.26&261. McCarthyCJ, Sheldon S, Ross CW, McCune WJ (1998): Cytogenetic abnormalitiesand therapyrelated myelodysplastic syndromesin rheumaticdisease. Arthritis Rheum 41 :1493-1496. Merlat A, Lai JL, Sterkers Y, Demory JL, Bauters F, PreudhommeC, Fenaux P (1999): Therapyrelated myelodysplastic syndromeand acute myeloid leukemiawith 17p deletion. A reporton 25 cases. Leukemia 13:25&257.

174

MYELODYSPLASTIC SYNDROMES

MichaudJ, Wu F, OsatoM, CottlesGM, YanagidaM,Asou N, ShigesadaK,Ito Y,Benson KF, Raskind WH, RossierC, AntonarakisSE, IsraelsS, McNicol A, Weiss H, HorwitzM, ScottHS (2002): In vitro analysesof known andnovel RUNXUAMLImutationsin dominantfamilialplateletdisorder with predispositionto acutemyelogenousleukemia:implicationsfor mechanismsof pathogenesis. Blood 99:1364-1372. Misawa S, Horiike S (1996): TP53 mutations in myelodysplastic syndrome. Leuk Lymphoma 23:4 17-422. MitelmanF, JohanssonB, MertensF, editors(2008): MitelmanDatabaseof ChromosomeAberrations in Cancer.http://cgap.nci.nih.gov/Chmmosomes/Mitelman. MohamedaliA, GakenJ, TwineNA, IngramW, WestwoodN, LeaNC,HaydenJ, DonaldsonN, Aul C, GattermannN, GiagounidisA, GermingU, List AF, MuftiGJ (2007): Prevalenceand prognostic significanceof allelic imbalanceby single-nucleotidepolymorphismanalysis in low-risk myelodysplasticsyndromes.Blood 1103365-3373. Morel P, HebbarM, Lai JL,Duhamel A, PreudhommeC, Wattel E, BautersF, Fenaux P (1993): Cytogenetic analysis has strong independentprognostic value in de novo myelodysplastic syndromesand can be incorporatedin a new scoring system: a reporton 408 cases. Leukemia 7~1315-1323. Nakao M, HoriikeS, Fukushima-NakaseY,NishimuraM, FujitaY, TaniwakiM, OkudaT (2004): Novel loss-of-functionmutationsof thehaematopoiesis-related transcription factor,acutemyeloid leukaemia VRunt-relatedtranscriptionfactor 1. detected in acute myeloblastic leukaemiaand myelodysplasticsyndrome.Br J Haematol 125:709-719. NeubauerA, GreenbergP, NegrinR, GinztonN, Liu E (1994):Mutationsin the rasproto-oncogenesin patientswith myelodysplasticsyndromes.Leukemia 8:638-641. Niimi H, HaradaH, HaradaY,Ding Y,ImagawaJ, InabaT, KyoT, KimuraA: (2006):Hyperactivation of the RAS signalingpathwayin myelodysplasticsyndromewith AMLl/RUNXl pointmutations. Leukemia 20:635-644. 1, StrombeckB, Theilgaard-Monch K, Nilsson L, Eden P,OlssonE, Minsson R, Astrand-Grundstriim Anderson K, Hast R, Hellstrom-LindbergE, SamuelssonJ, Bergh G, Nerlov C, JohanssonB, SigvardssonM. BorgA, JacobsenSE (2007): The molecularsignatureof MDS stemcells supports a stem-cell origin of 5q myelodysplasticsyndromes.Blood 1 10:3005-30 14. NorrbackKF, Roos G (1997): Telomeresand telomerasein normaland malignanthaematopoietic cells. Eur J Cancer 33:774-780. J, ParganasE, Ihle NuciforaG, Begy CR. KobayashiH, RoulstonD, ClaxtonD, Pedersen-Bjergaard JN, Rowley JD ( I 994): Consistent intergenicsplicing and productionof multiple transcripts betweenAMLI at 21q22 and unrelatedgenes at 3q26 in (3;2l)(q26;q22)translocations.Proc Nail Acad Sci USA 91:4004-4008. Ogata K, Tamura H (2000): Thrombopoietinand myelodysplastic syndromes. inl J Hematol 72:173-177. PaduaRA, GuinnBA, Al-SabahAI, Smith M, TaylorC, PetterssonT, Ridge S, CarterG, White D, OscierD, ChevretS, West R (1998): RAS, FMS and p53 mutationsand poor clinical outcomein myelodysplasias:a 10-yearfollow-up. Leukemia 122387-892. ParkerJE,Mufti GJ, Rassool F, Mijovic A, Devereux S, PagliucaA (2000): The role of apoptosis, proliferation,and the bcl-2-relatedproteinsin the myelodysplasticsyndromesand acutemyeloid leukemia secondaryto MDS. Blood 96:3932-3938. PaulssonK. Sall T, FioretosT, MitelmanF,JohanssonB (2001): The incidenceof trisomy8 as a sole chromosomalaberrationin myeloid malignaciesvariesin relationto gender,age, prioriatrogenic genotoxic exposure,and morphology.Cancer Genet Cytogenet 130:160- I 65. PaulssonK, HeidenbladM. StrombeckB, StaafJ,JonssonG, Borg A, FioretosT,JohanssonB (2006): High-resolutiongenome-wide array-basedcomparativegenome hybridizationreveals cryptic

REFERENCES

175

chromosomechangesin AML and MDS cases with trisomy 8 as die sole cytogenetic aberration. Leukemia 20840-846. Pedersen-BjergaardJ, Andersen MK, Christiansen DH (2000): Therapy-relatedacute myeloid leukemia and myelodysplasia afterhigh-dose chemotherapyand autologousstem cell transplantation. Blood 95:3273-3279. Pedersen-BjergaardJ, Andersen MK, Christiansen DH, Nerlov C (2002): Genetic pathways in therapy-relatedmyelodysplasia and acute myeloid leukemia. Blood 99: 1909- 1912. Pedersen-BjergaardJ, Andersen MT, AndersenMK (2007): Genetic pathwaysin the pathogenesisof therapy-relatedmyelodysplasia and acute myeloid leukemia. Hematology 2007:392-397. PekarskyY. RynditchA, Wieser R, FonatschC, GardinerK (1997): Activationof a novel gene in 3q2 I and identificationof intergenicfusion transcriptswith ecotropic viral insertionsite I in leukemia. Cancer Res 57:3914-3919. PellagattiA. CazzolaM,GiagounidisAA, Malcovati L, PortaMG, Killick S, CampbellLJ, WangL, LangfordCF, Fidler C, Oscier D, Aul C, Wainscoat IS, Boultwood J (2006): Gene expression profiles of CD34 cells in myelodysplastic syndromes: involvement of interferon-stimulated genes and correlation to FAB subtype and karyotype. Blood 108:337-345. PierreRV, HoaglandHC ( 1972): Age-associated aneuploidy:loss of Y chromosomefromhumanbone marrowcells with aging. Cancer 30:889-894. Qian Z, Femald AA, Godley LA, Larson RA, Le Beau MM (2002): Expressionprofilingof CD34+ hematopoietic stedprogenitorcells reveals distinct subtypes of therapy-relatedacute myeloid leukemia. Proc Natl Acad Sci USA 99: 14925-14930. RaynaudSD, Baens M. GrosgeorgeJ, RodgersK, Reid CD, Dainton M, Dyer M, FuzibetJG, Gratecos N, Taillan B, AyraudN, MarynenP (1996): Fluorescencein situ hybridizationanalysisof t(3;12) (q26p13): a recurringchromosomalabnormalityinvolving the TEL gene (ETV6) in myelodysplastic syndromes. Blood 88:682-689. Ridge SA, Worwood M, Oscier D, Jacobs A, PaduaRA (1990): FMS mutationsin myelodysplastic, leukemic, and normal subjects. Proc Natl Acad Sci USA 87: 1377-1380. RosenbauerF, WagnerK, KutokJL, Iwasaki H, Le Beau MM, OkunoY,Akashi K, Fiering S, Tenen DG (2004): Acute myeloid leukemia induced by gradedreductionof a lineage-specific transcription factor, PU. I . Nal Genet 36:624-630. Ross TS, BernardOA, Berger R, Gilliland DG ( 1 998): Fusion of Huntingtininteractingprotein I to platelet-derivedgrowth factor beta receptor(PDGFbetaR)in chronic myelomonocytic leukemia with t(5;7)(q33;qlI.2). Blood 91:4419426. Rowley JD (1999): The role of chromosome translocations in leukemogenesis. Semin Hematol 3659-72. Rowley JD (2000): Molecular genetics in acute leukemia. Leukemia 14513-517. Rowley JD, Olney W (2002): Internationalworkshopon the relationshipof priortherapyto balanced chromosome aberrations in therapy-relatedmyelodysplastic syndromes and acute leukemia: overview report. Genes Chromosomes Cancer 33:33 1-345. Rowley JD, Reshmi S, Sobulo0.Musvee T, AnastasiJ, RaimondiS, SchneiderNR, BarredoJC,Cantu ES, SchlegelbergerB, Behm F, Doggett NA, BorrowJ, Zeleznik-Le N (1997): All patientswith the t( I 1 ;16)(q23;p13.3) that involves MLL and CBP have treatment-relatedhematologic disorders. Blood 90:535-541. Rubin CM, Larson RA, Bitter MA, Carrino JJ, Le Beau MM, Dim MO, Rowley JD (1987): Association of a chromosomal 3;2 I translocationwith the blast phase of chronic myelogenous leukemia. Blood 70:1338-1342. RubinCM,Larson RA, AnastasiJ, WinterJN, ThangaveluM,VardimanJW, Rowley JD, Le Beau MM ( 1990): t(3;2 I )(q26;q22): a recurringchromosomal abnormalityin therapy-relatedmyelodysplastic syndromeand acute myeloid leukemia. Blood 76:2594-2598.

'

176

MYELODYSPIASTIC SYNDROMES

SaunthararajahY, NakamuraR, Nam JM, Robyn J, LoberizaF, MaciejewskiJP,Simonis T, Molldrem J, Young NS, Barrett AJ (2002): HLA-DR15 (DR2) is overrepresented in myelodysplastic syndromeand aplasticanemiaand predictsa response to immunosuppressionin myelodysplastic syndrome. Blood 100:1570-1574. Secker-WalkerLM (1998): General Reporton the EuropeanUnion ConcertedAction Workshopon 1 lq23, London, UK, May 1997. Leukemia 12:776-778. Shannon KM, O’Connell P, MartinGA, PaderangaD, Olson K, Dinndorf P, McCormickF (1994): Loss of the normalNFI allele from the bone marrowof childrenwith type 1 neurofibromatosisand malignantmyeloid disorders.N Engl J Med 330597-601. Shih LY, Huang CF, Lin TL, Wu JH, Wang PN, Dunn P, Kuo MC, Tang TC (2005): Heterogeneous patternsof CEBPalphamutationstatusin the progressionof myelodysplasticsyndromeandchronic myelomonocytic leukemia to acute myelogenous leukemia. Clin Cancer Res 1 I :1821-1 826. Shiseki M, KitagawaY,Wang YH, Yoshinaga K, Kondo T, KuroiwaH, OkadaM, Mori N, MotojiT (2007): Lack of nucleophosmin mutation in patients with myelodysplastic syndrome and acute myeloid leukemia with chromosome 5 abnormalities.k u k Lymphoma 48:2141-2144. Side LE, CurtissNP,Tee1K, KratzC, WangPW,LarsonRA, Le Beau MM, ShannonKM (2004): RAS, FLT3, and TP53 mutations in therapy-relatedmyeloid malignancies with abnormalities of chromosomes5 and 7. Genes Chromosomes Cancer 39:217-223. Siitonen T, SavolainenER, KoistinenP (1994): Expressionof the c-kit proto-oncogenein myeloproliferative disordersand myelodysplastic syndromes. Leukemia 8:631-637. Sitailo S, Sood R, BartonK, Nucifora G (1 999): Forcedexpression of the leukemia-associatedgene EVIl in ES cells: a model for myeloid leukemia with 3q26 rearrangements.Leukemia 13:1639-1645. Smadja N, Krulik M, HagemeijerA, van der Plas DC, Gonzalez Canali G, de GramontA (1989): Cytogeneticandmolecularstudies of the Philadelphiatranslocationt(9;22) observed in a patient with myelodysplastic syndrome.Leukemia 3:236-238. Sol6 F, Espinet B, Sanz GF, CerveraJ, CalasanzMJ, Luno E, Pneto F, Granada1, HernandezJM, CigudosaJC, Diez JL, Bureo E, MarquCsML, ArranzE, Rios R, MartinezClimentJA, VallespiT, Florensa L, Woessner S (2000): Incidence, characterizationand prognostic significance of chromosomal abnormalities in 640 patients with primary myelodysplastic syndromes. Br J Haematol 108:346-356. Sol6 F, Luiio E, SanzoC, Espinet B, Sanz GF, CerveraJ, CalasanzMJ, CigudosaJC,Milla F, Ribera JM, Bureo E, Marquez ML, Arranz E, Florensa L (2005): Identificationof novel cytogenetic markerswith prognostic significance in a series of 968 patients with primary myelodysplastic syndromes. Haematologica 90: I 168-1 178. Song WJ, Sullivan MG, LegareRD, HutchingsS, Tan X, KufrinD, RatajczakJ, Resende IC, Haworth C, Hock R, Loh M, Felix C, Roy DC, Busque L, KurnitD, Willman C, Gewirta AM, Speck NA, BushwellerJH,Li FP, GardinerK, Poncz M, Maris JM, GillilandDG (1 999): Haploinsufficiencyof CBFA2 causes familial thrombocytopeniawith propensityto develop acute myelogenous leukaemia. Nat Genet 23:166-175. Sood R, Talwar-TrikhaA, ChakrabartiSR, Nucifora G ( 1 999): MDS 1EVI I enhances TGF-beta1 signaling and strengthensits growth-inhibitoryeffect but the leukemia-associatedfusion protein AMLI/MDSlEVl1, productof the t(3;2 I), abrogatesgrowth-inhibitionin responsetoTGF-beta]. Leukemia 13:34&357. Spitzer G, Verma DS, Dicke KA, Smith T, McCredie KB (1979): Subgroupsof oligoleukemia as identified by in vitro agar culture. h k Res 3:29-39. SteensmaDP, Dewald GW, LashoTL,Powell HL,McClureRF, Levine RL, Gilliland DG, TefferiA (2005): TheJAK2V6 17Factivatingtyrosine kinasemutationis an infrequentevent in bothatypical myeloproliferativedisordersand myelodysplastic syndromes. Blood 106:1207- 1209.

REFERENCES

177

Strom SS, Velez-Bravo V, Estey EH (2008): Epidemiology of myelodysplastic syndromes. Semin Hemarol45:8-13. Tidow N, Kasper B, Welte K (1998): Clinical implications of G-CSF receptor mutations.Crit Rev Oncol Hematol28: 1-6. Tien HF, Wang CH, ChuangSM, Chow JM, Lee FY, Liu MC, Chen YC, Shen MC, Lin DT, Lin KH ( 1994): Cytogenetic studies, ras mutation, and clinical characteristicsin primary myelodysplastic syndrome. A study on 68 Chinese patients in Taiwan. Cancer Genet Cytogenel 74:40-49. Tosi S . SchererSW, Giudici G, Czepulkowski B, Biondi A, KearneyL (1 999):Delineationof multiple deleted regions in 7q in myeloid disorders. Genes Chromosome.v Cancer 25:384-392. Toyama K, OhyashikiK, YoshidaY,Abe T,Asano S, Hirai H, HirashimaK, Hotta T, KuramotoA, Kuriya S,et a1 (1993):Clinical and cytogenetic findings of myelodysplastic syndromesshowing hypocellular bone marrow or minimal dysplasia, in comparison with typical myelodysplastic syndromes. Int J Hematol58:53-61. United Kingdom Cancer Cytogenetics Group (UKCCG) (1992):Loss of the Y chromosome from normal and neoplastic bone marrows.Genes Chromosomes Cancer 5:83-88. Vallespi T. ImbertM, Mecucci C,PreudhommeC , Fenaux P (1998):Diagnosis, classification, and cytogenetics of myelodysplastic syndromes.Haematologica 83:258-275. van de LoosdrechtAA, WestersTM, WestraAH, DragerAM, van der Velden VH, OssenkoppeleGJ (2008): identification of distinct prognostic subgroupsin low- and intermediate-I-risk myelodysplastic syndromesby flow cytometry. Blood I 1 1:1067- 1077. Van den Berghe H, Michaux L (1997): 5q-, twenty-five years later: a synopsis. Cancer Genet Cytogenet 94: 1-7. VardimanJ W (2003):Myelodysplasticsyndromes,chronic myeloproliferativediseases, and myelodysplasticlmyeioproliferativediseases. Semin Diagn Path0120 154- 179. VenkatachalamS. Shi YP, Jones SN, Vogel H, BradleyA, Pinkel D, DonehowerLA (1 998):Retention of wild-type p53 in tumors From p53 heterozygous mice: reductionof p53 dosage can promote cancer formation.EMBOJ 17:46574667. WalkerJ, Flower D, Rigley K (2002):Microarraysin hematology. CurrOpin Hematol9:23-29. WangP, SpielbergerRT,ThangaveluM, ZhaoN, Davis EM, lannantuoniK. LarsonRA, Le Beau MM (1997): dic(5; 17): a recumng abnormality in malignant myeloid disorders associated with mutations of TP53. Genes Chromosomes Cancer 20:282-29 1. Wang PW, EisenbartJD, EspinosaR 3rd, Davis EM, LarsonRA, Le Beau MM (2000):Refinementof the smallest commonly deleted segment of chromosome 20 in malignant myeloid diseases and development of a PAC-basedphysical and transcriptionmap. Genomics 67:28-39. WattelE. Lai JL,HebbarM, PreudhommeC, GrahekD, Morel P,BautersF, FenauxP (1993):De novo myelodysplasticsyndrome(MDS) with deletion of the long armof chromosome20: a subtype of M D S with distinct hematological and prognostic features?Leuk Res 17:921-926. WeimarIS, BourhisJH, De Cast GC, GerritsenWR (1994):Clonality in myelodysplasticsyndromes. Leuk Lymphoma 13:215-221. Wells DA, Benesch M. LokenMR, VallejoC, Myerson D, LeisenringWM, Deeg HJ (2003):Myeloid and monocytic dyspoiesis as determinedby Bow cytometricscoring in myelodysplastic syndrome correlateswith the IPSS and with outcome after hematopoietic stem cell transplantation.Blood 102:394-403. West RR, Stafford DA, White AD, Bowen DT, PaduaRA (2000):Cytogenetic abnormalitiesin the myelodysplastic syndromesand occupational or environmentalexposure. Blood 95:2093-2097. Wiktor A, Rybicki BA, Piao Z S , Shurafa M, Barthel B, Maeda K, Van Dyke DL (2000):Clinical significance of Y chromosome loss in hematologic disease. Gmes Chromosomes Cancer 27:11-16.

178

MYELODYSPIASTIC SYNDROMES

Xu D, GruberA, PetersonC, Pisa P (1998): Telomeraseactivity and the expressionof telomerase componentsin acute myelogenous Leukaemia.Br JHaematol 102:1367- 1375. Zhang Y, Rowley JD (2006): Chromatinstructuralelements and chromosomal translocationsin leukemia. DNA Repair 511 282-1297. Zhao N, Stoffel A, Wang PW, Eisenbarf JD, Espinosa R 3rd, Larson RA, Le Beau MM (1997): Moleculardelineationof the smallestcommonly deleted region of chromosome5 in malignant myeloid diseasesto 1-1.5 Mb and preparationof a PAC-basedphysical map. ProcNatl Acad Sci USA 94:69484953. ZippererE, Wulfert M, GermingU, Haas R, GattermannN (2008): MPL 5 15 and JAK2 mutation analysis in MDS presentingwith a platelet count of more than 500 x lO(9)L. Ann Hematol 87:413415. ZijchbauerS , Gsur A, Gotzl M,WallnerJ, LechnerK, PirkerR (1994): MDRl gene expressionin myelodysplastic syndrome and in acute myeloid leukemia evolving from myelodysplastic syndrome.Anticancer Res 14:1293-1295.

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CHAPTER7

Chronic Myeloid Leukemia.

THOAS FIORETOS and BERTILJOHANSSON

Chronicmyeloid leukemia(CML) is a clonal bone marrow(BM) disease characterizedby neoplasticoverproductionof, mainly, granulocytes.In the Westernworld, CML accounts forapproximatelyI5-20% of all cases of leukemia,with an incidenceof 1/100,000 peryear. CML occurs in all age groupsbut is most common in older people with a medianage of 65 years at the time of diagnosis.There isa slight male preponderance.Studiesof atomic bomb survivorsexposed to ionizing radiationhave shown an excess risk of CML, but otherwiseepidemiologicalstudies have failed to find any strongoccupationalor lifestyle risk factorsfor developingCML (Ichimaruet al., 1978; Bjork et al., 2001). At the time of diagnosis, the white blood cell (WBC) count is high, typically near 200 x 109L.The BM morphologyis characterizedby granulocyticand megakaryocytic hyperplasia.with the megakaryocytestypicallybeing small and often displayinghypolobatednuclei. Eosinophiliaand,especially,basophiliaare common,and in one-thirdof the cases a certain amount of myelofibrosisis present. In contrastto acute lymphoblastic leukemia(ALL) andacutemyeloid leukemia(AML), thehematopoieticmaturationin CML proceedsin a seemingly orderlymannerin the differentlineages withoutany maturation arrest. The leukemogenic event in CML is thought to occur at the level of the pluripotent hematopoieticstem cell (HSC). This explainswhy most hematopoieticlineages,including neutrophils,eosinophils, basophils,erythroidcells, and megakaryocytes,as well as B-ceH precursorsand early, but not mature,T-cells or naturalkiller cells are involved in the disease process (Jiang et al., 2007). In fact, there is evidence suggesting that CML may arisein a progenitorcell even earlierin the hierarchythan the HSC, possibly in a hemangioblast capable of generatingboth blood and endothelialcells (Gunsiliuset al., 2000). As will be discussedlaterin thischapter,the treatmentof CML haschangeddramatically duringrecentyears with the introductionof tyrosinekinase inhibitors(TKI)targetingthe productof the underlyingcytogeneticand molecularlesion in CML. This has also resulted in an altereddiseasecourseof CML, with most patientshavingstartedtherapywith TKI still remainingin clinical andcytogeneticremission.Withoutnovel treatmentmodalities,but also in a fractionof patientsreceiving such therapies,the initial,relativelybenign chronic phase (CP) of CML, which on average(but with wide case-to-casevariation)lasts about

Cancer Cytogenetics, Third Edition, edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons,Inc.

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3 years,typicallythen entersa more malignantacceleratedphase (AP) and eventuallythe terminalblast crisis (BC). CMLBC is characterizedby an increasein the numberof immaturecells in the BM and peripheralblood by progressiveanemiaand thrombocytopenia,sometimesby extramedullary accumulationsof blast cells, and by a reducedresponseto therapy.The morphologic characteristics of theleukemicblastsvarywitheithermyeloblasticorlymphoblasticfeatures predominating.Theblastsarein mostinstancesphenotypicallyindistinguishable fromAML cells, but in one-thirdof the CML BC they resembleimmaturelymphoidcells and also expressimmunophenotypes typicaloflymphoblasts.Recently,myeloidBChasbeenreported tooriginatein a moredifferentiatedmyeloid-restricted progenitorcell, mostlikelythroughthe acquisitionof mutationsthatconferself-renewalcapacity(Jamiesonet al., 2004). CMLis one of the best-studiedhumanmalignanciesandhas servedas a paradigmforthe elucidationof how geneticchangescausecells to becomemalignant.CMLis also one of the first malignancies in which a therapy targeting the underlying molecular lesion has improvedthe clinical outcomeof patients.However,despite this progressmany questions remainunanswered.With a focus on cytogenetic and moleculargenetic aspects of CML, this chapterwill tryto addresssomeimportantissues. How does thet(9;22)orvariantsof this translocationarise?Whatare the mechanismsby which this rearrangement causes leukemia?Whicharethe novel treatmentregimensin CML,andhow have they affectedthe way such patients should be monitored clinically? Which secondary genetic changes are responsiblefor the progressionof CP to BC, and how are these changes influencedby thegiventreatment?Wheneverpossible,clinicallyrelevantissues will be addressedwith an emphasison the implicationsof cytogenetic and moleculargenetic findings in CML.

THE DISCOVERY AND CHARACTERIZATIONOF THE PHILADELPHIA CHROMOSOME The Philadelphiachromosomewas the firstconsistentneoplasia-associatedchromosomal abnormalityreported;its discoverywas a milestonein cancercytogenetics.By studyingthe leukemiccells of CMLpatients,Nowell and Hungerford(1960) identifieda small G-group chromosomethatwas namedthe Philadelphiachromosome(Ph')afterthe city in which it was discovered.The use of the superscriptanticipatedthe discoveryof new aberrationsthat would be designatedPh', Ph3, etc, butthis namingprinciplewas neverimplementedandthe small derivativechromosome(see later)is now referredto as Ph. The truenatureof the Ph chromosomewas at first unknown,but with the adventof variouschromosomebanding techniquesaround1970,it was shownto ariseas a resultof a translocationbetweenthelong armsof chromosomes9 and22, thatis, t(9;22)(q34;qI I), with the Ph chromosomebeingthe der(22)t(9;22)(Rowley, 1973). de Klein et al. ( 1 982) were ableto show thata small segmentof chromosome9, including parts of the ABLl (formerlyABL) oncogene, was translocatedto chromosome22, thus provingthe reciprocalnatureof the t(9;22). A subsequentmoleculargenetic study showed that a chimeric DNA fragment isolated from one CML case, apart from ABLI, also containedsequencesoriginatingfrom chromosome22 (Heisterkampet al., 1983). These datasuggesteda rolefor theABLI gene in CML,a hypothesisthatwas latersupportedby the findingsof an abnormallysized ABLl transcriptand ABLl proteinin the CML cell line K562 (Collins et al., 1984; Gale and Canaani, 1984; Konopkaet al., 1984) and in CML patients(Stamet al., 1985). Groffenet al. (1984) then isolatedand extendedthe regionon

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chromosome22 involved in the translocation,showing that the breakpointin 17 patients occurred within a limited region of 5.8 kb, which was termed the “breakpointcluster region” or bcr. Soon afterward,it was demonstratedthatbcr actuallywas a partof a larger gene (Heisterkampet al., 1985) referredto as BCR; the region in which the breakpoints occur in CML was then denoted bcr or M-bcr for “major breakpointcluster region.” Cloningof partialandfull-lengthchimericBCRIABLI cDNA clones and sequenceanalyses finally establishedthatthe resultof the Ph chromosomewas the generationof a BCRIABLI fusion gene (Heisterkampet al., 1985; Shtivelmanet al., 1985;Grosveldet al., 1986; MesMasson et al., 1986). Whenstudyingt(9;22)-positiveALL, it was notedthatonly some cases had a detectable rearrangement within M-bcr.The leukemic cells of the otherpatientswere soon found to contain an ABLl protein of a different size from the one observed in CML (Chan et al., 1987; Clarket al., 1987; Kurzrocket al., 1987). Subsequently,it was demonstrated that this abnormalABLl protein also containedantigenicdeterminantsderivedfrom the BCR protein(Walkeret al., 1987). Cloning of a chimericBCWABLI cDNA containinga smallerpartof BCR sequencesand the localizationof thebreakpointsto thefirstBCR intron finally provedthata BCWABLI fusion gene was also presentin this subtypeof Ph-positive ALL (Feinsteinet al., 1987; Hermanset al., 1987). As will be discussedin detail below, molecularcharacterizationof the chimericprotein latershowedthatthe tyrosinekinaseactivityof BCWABLI is indispensablefor leukemic transformationof t(9;22)-positiveleukemias(Lug0et al., 1990). The leukemogeniceffects of BCWABLl have now been studiedusing numerousmodel systems,whichhaverevealed that BCWABL1 affects several signal transductionpathwaysthat influenceproliferation, apoptosis,and adhesionof the leukemic cells (Deiningeret al., 2000: Melo and Deininger,2004; Ren, 2005). A majortherapeuticbreakthrough finallycamewith the development of imatinib, a drug that targets the tyrosine kinase activity of the BCFUABLI protein (Drukeret al., 1996).

CYTOGENETIC ABNORMALITIES IN CML CP Since the discoverythat the Ph originatedthrougha t(9;22)(q34;q1 I), many thousandsof CML have been cytogeneticallyanalyzed,and such analyseshave clearlyestablishedthat roughly 85% of cases display a standard,cytogeneticallybalancedt(9;22) (Fig. 7.1). The remaindereitherharborvarianttranslocations(see later)or seemingly normal karyotypes,

9

der(9)

22

der(22)

FTGURE 7.1 Partial karyotype showing the t(9;22)(q34;q11). Arrows indicate breakpoints on the derivative chromosomes.

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in which the BCR andABLl genes recombinethroughcytogeneticallycrypticinsertionsor othermorecomplex chromosomalrearrangements thatcan be visualizedusing fluorescent in situ hybridization(FISH)with probesspecific for the two genes or throughmolecular genetic methods.Accordingto prevailingopinionsand recentWHOdiagnosticguidelines (Vardimanet al., 200 I), CML as a diagnosticentity should be reservedfor cases carrying eithera standardor variantt(9;22) or its molecularequivalent,the BCWABLl fusion gene. Thet(9;22) orits variantsaredetectedas the sole cytogeneticchangein about80-90%of CML diagnosedin CP. The remainingcases may display additionalkaryotypicchanges, typically loss of the Y chromosome, 8, Ph, and i( 17q), that is, abnormalitiesthat are similarto the ones detected at quite high frequencies(6040%; see later) upon disease progressioninto AP or BC (Johanssonet al., 2002). Consequently,the presenceof such changes in CML CP may have clinical and prognosticramifications.Sokal et al. (1988) found thatpatientswith secondarychangespresentalreadyat the time of diagnosishad a shortersurvival,but with survivalcurvesfor those with and withoutadditionalchangesnot diverginguntil afterthe2-year point.However,it is importantto note thatthe significanceof prognostic factors may change dramaticallywith the introductionof novel treatment strategies.So far, data on the clinical significanceof additionalaberrationsin CML CP at diagnosis, in patients subsequentlyreceiving imatinib, are relatively sparse (Cortes et al., 2003; O’Dwyer et al., 2004). Cortes et al. (2003) reportedthat the presence of additionalcytogeneticchangesatdiagnosisin CP was not an importantfactorfor achieving a major or complete cytogenetic response (CCR) with imatinib, but that it was an independentpoor prognosticfactor for survival.Moreover,the presence of an i( 17q) was associatedwith a lower rateof cytogenetic response, whereas 8 was associatedwith a relatively high response rate. In the study by O’Dwyer el al. (2004), investigating pretreatment factorsassociatedwith hematologicrelapseafterinitiationof imatinibtherapy, it was found that the presenceof secondarychromosomeaberrationsat diagnosisconstitutedthe highestrisk factorfor a subsequenthematologicrelapse.Althoughthe numberof patientsstudiedwas relativelysmall (n = 22), it was again suggestedthatchromosome17 abnormalitiesmay be associated with an inferior outcome. The significance of the emergenceof additionalcytogeneticchanges in patientsalreadyreceiving treatmentwith imatinibwill be discussed in the sections to follow. In 2-10% of cases, the BCWABLl chimera is formed through so-called variant translocations.Traditionally,two variantsubgroupshavebeenrecognized.In simplevariant translocations,the segmentlost from22q is translocatedonto anotherchromosomethan9, whereasthreeor more chromosomesare involved in complex varianttranslocations.In a surveyof close to 600 CMLcases with variantrearrangements, it was demonstratedthatthe distributionof the breakpoints,in additionto 22ql1, in such cases clearly exhibited a nonrandompattern(Johanssonet al., 2002). Although all chromosomeswere involved, therewas a markedclusteringto chromosomalbands1p36,3p21,5ql3,6p2 1.9q22,l lq 13, 1 2 ~ 1 3 ,1 7 ~ 1 3 ,17q21, 17q25, 19q13, 2 1 ~ 2 2 ,22q12, and 22q13, suggesting that these regionsmay be particularlyproneto breakage.Some specific variantswere morecommon thanotherswith t(3;9;22)(p21;q34;q1 I ) andt( 17;22)(q25;q1 1 ) being reportedin morethan 10 cases. Morerecently,Fisheret al. (2005) describedthe breakpointdistributionin a series of 289 cases of CMLwith variantt(9;22),the largestindependentseries publishedto date, They observed that the distributionof breaks only partly agreed with literaturedata, identifyingseveral additionalchromosomalbreakpointclusters. Moreover,a significant positive correlationwas observed between breakpointlocations and CG composition, suggestingthatcertainfeaturesin the genome that vary with CG content(e.g., opennessof

+ +

+

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chromatinstructure,repetitive elements such as A h ) , could account for the observed clustering. Consideringthat the varianttranslocationsaffect additionalchromosomalregions,one would perhapsexpect that these additional“hits” resultin a differentdisease phenotype. Several studies have addressed the possible influence of variant translocationon the durationof CP, arrivingat contradictoryresults(Johanssonet al., 2002). Althoughtoday the prevailingopinionis thatthe clinical,prognostic,andhematologicfeaturesof CMLwith varianttranslocationare not distinctfrom those seen in standardt(9;22), most reportsare basedon small series or on literaturereviews. Reidet al. (2003) used FISHto investigatea series of 54 patients with variant t(9;22) and reportedan adverse prognostic outcome associatedwith such abnormalities.The poorprognosticoutcomein the groupwith variant t(9;22)was foundto be dueto an increasedfrequencyof concomitantdeletions(40%versus 14% in standardt(9;22);see also discussionto follow) atthe reciprocalABLIIBCR fusionon the der(9), suggesting that the latter change, ratherthan any other genomic variable, constitutedthe criticalprognosticfactor.However,comparinga series of 43 patientswith varianttranslocationswith a largecohortof standardt(9;22), all treatedwith imatinib,no differences were observed in cytogenetic response rate, overall survival or durationof response (El-Zimaityet al., 2004). Thus, the availabledata suggest that the prognostic difference,if any,betweenvariantand standardt(9;22)CMLseems to be negligible,at least in the imatinibtreatmentera. Considerableinteresthasalsocenteredon thequestionwhetherthevarianttranslocations areformedby multiplesimultaneousbreaksandjoiningor if they arisethroughtwo or more consecutive translocations.Evidence for the latter has emerged from rare instances of coexistenceof standardand variantPh translocationsin the samepatients(Bernstein,1988; Ishiharaand Minamihisamatsu,1988) and from investigationsby FISH demonstrating evolutionfroma standardto a variantt(9;22)(Reidet al., 2003). However,evidenceis also at hand suggesting that complex translocationsmay be caused by a single genetic event (Fitzgeraldand Morris, 1991; McKeithanet al., 1992; Yehuda el al., 1999). While the standardt(9;22) at the cytogeneticlevel is seeminglybalanced,severalFISH analyseshave revealedthatdeletionsat the derivativechromosome9 arepresentin IO- 15% of cases (Sinclairet al., 2000; Huntlyet al., 2001,2003; Lee et al., 2003; Quintas-Cardama et al., 2005; Kreil et al., 2007). The deletionshave been shown to be of variablesize, often extending several megabases both on chromosome9- and chromosome 22-derived sequences,which meansthatthe reciprocalABLUBCR fusion and adjacentsequenceson the derivativechromosome9 are lost. Furthermore,several studieshave obtainedevidence in favorof the deletionstakingplace at the formationof the t(9;22), thatis, they do not occur duringdisease evolution (Huntlyet al., 2001; Reid and Nacheva,2005). Numerousinvestigationshave addressedthe possibleprognosticimpactof deletionsat the der(9), with most groups reportingadverse prognostic features, including shorter survival times in cases with deletions (Sinclair et al., 2000; Huntly et al., 2001, 2003; Kolomietz et al., 2003; Lee et al., 2003), whereas others have failed to detect such differences(Yoonget al., 2005; Quintas-Cardama et al., 2005). In a recentstudy,performed in the contextof a randomizedclinicaltrialinvestigatinginterferon-alpha (IFN-a)as a firstline therapy,a DNA-baseddeletion screen was used, demonstratingthat 17%of patients harboreddeletionsat the der(9)(Kreil et al., 2007). The deletionscouldbe furtherclassified into three groups: deletions encompassingboth chromosome9- and chromosome 22derivedsequences or deletions affecting only sequencesupstreamor downstreamof the A B L I B C R fusion point. As a group,the presenceof a deletionwas not associatedwith a

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poorprognosis,butwhen subdivided,breakpoint-spanning deletionswereassociatedwith a poor prognosis, whereas those with either upstreamor downstreamdeletions displayed improvedsurvival.Whetherdeletionmappingat the der(9) of CML patientsat diagnosis will turnout to be a clinical useful prognosticfactor in patientstreatedwith imatinibis currentlycontroversial(Huntlyet al., 2003; Quintas-Cardama et al., 2005); a final verdict must await furtherstudies with longer follow-up times. In the searchfor submicroscopicgenome-widecopy numberchanges in CML APBC (see later),a few studieshave also investigatedCMLCPsamples.Using BAC arrayswith a limited( I Mb) resolution,no frequentor recurrentchanges,apartfromthe der(9)deletions, multiplesupposedlypolymorphiccopy numbervariantsand a few changes known to be associatedwith diseaseprogression,have beendetectedin CPsamples(Hosoyaet al., 2006; Brazmaet al., 2007). Nor have any recurrentdeletionsbeen identifiedso far in CMLCP using higherresolution(250 K) SNP arrays(Mullighanet al., 2008). It remainsto be seen whetherfuturestudiesperformedon higherresolutionarrayswill identifysubmicroscopic changes of prognosticor pathogeneticrelevance in CML CP.

MOLECULAR PATHOLOGY OF THE t(9;22)(q34;qll) IN CML As a resultof the t(9;22)in CML,two maintypesof fusiongenes,designatedP210 andP230 BCWABLI, are generatedthat differ dependingon the variable numbersof BCR exons includedin thefusiongenes (Fig. 7.2). A shortervariant,P190 BCWABLi, whichis foundin the greatmajorityof patientswith Ph-positiveALL, is discussedin Chapter9. The sizes of thedifferentfusiongenes dependon the locationof thebreakpointswithintheBCR gene;the great majorityof the breaks(>95%)in CML occurin the approximately4.4kb M-bcr, which consists of BCR exons 12-15 (also designated bl-b4) and interveningintronic sequences(Deiningeret al., 2000). In a small fractionof the patients,the breakpointsare located furtherdownstreambetween BCR exons 19-21, in the 2.1 kb micro (p)-bcr. The latterbreakpoint,resultingin a P230 BCWABLI fusion transcript(also termede I9a2), was originally thought to be associated with a better prognosis and chronic neutrophilic leukemia (Pane et al., 1996), but several subsequentreportshave identified P230 BCW ABLl also in patientswith typicalCML. In a review of 23 publishedcases expressingthe P230BCWABLI fusion gene, it was concludedthatwhile most suchpatientsdisplaya more indolentdiseasecourse,severalhave shownpoortreatmentresponseorhavebeen diagnosed in advancedstagesof CML,thusquestioninganoverallfavorableprognosisin thissubgroup of patients(Verstovseket al., 2002). Withthe use of RT-PCR,a numberof differentunusual in-frametranscriptshave also been identifiedin CML,for example,BCR exon 6 fused with ABLl exon 2, fusiontranscriptsin whichexon 2 of ABLl is missing (el a3, e I3a3,e 14a3),or “bizarre”insertionsor breakpointswithin exons (Barnesand Melo, 2002). Thebreakpointsin theABLl gene at9q34 aredistributedovera largearea( > 300 kb)and, in general,occur5‘ of ABL exon 2 in the intronsbetweenexons I b and l a or exons l a and2 (Jiang et al., 1990). Regardlessof the location of the ABLl breakpoints,the first two alternativeexons ( I a and I b) arealwayssplicedout duringmRNA maturation,with exon 2 of ABLl typically becomingjuxtaposedto the variable5’ partsof BCR. Why and how does the t(9;22) or the correspondingBCWABLI recombinationtake place? As is the case for most chromosomaltranslocations,the fundamentalmechanisms areunknown.The perhapsmost widely acceptedexplanationis behindthe rearrangement that the t(9;22) is a randomevent that we become aware of when it confers a selective

MOLECULAR PATHOLOGY OF THE t(9;22)(q34;q11 ) IN CML

18 5

FIGURE 7.2 Schematic depiction of the main BCR/ABL1fusion gene variants, (a) To the left, the genomic structure of the BCRgene, spanning approximately I38kb and containing 23 exons, is displayed. The breakpoints in most Philadelphia-positiv e ALL fall in the minor breakpoint cluster region (m-bcr), located in the 3' half of the approximately 72 kbfirstintron. The great majority of the breaks in CML occur in the approximately 4.4 kb major breakpoint cluster region (M-bcr), which consists of BCRexons 12-15 (also designated bl-b4) and intervening intronic sequences. In a small fraction of CML patients, the breakpoints are located further downstream between BCRexons 19-21 (also designated e l9-e21), in the 2.1 kb micro (ì)-ïï ð To theright,the genomic structure of the ABU gene, spanning about 174 kb and containing two alternativefirstexons, 1 b and 1 a, followed by exons 2 through 11, is shown. The breakpoints in ABLlare located in the introns between exons 1 b and 1 a, 1 a and 2, or5'of 1 b. (b) To the left, approximate sizes ofBCRexons 1 -23, with the different breakpoints at the cDNA level indicated by arrows, are depicted. To theright,the ABLlcDNA with exon 1 a followed by exons 2-11 is shown. The arrow indicates the breakpointat the cDNA level upstream ofABLlexon 2. (c) Representation of the fusion gene variants P190 BCR/ABL1(BCRexon 1 fused to ABLlexons 2-11; also designated ela2), P210 BCR/ABL1(BCRexons 1-13 or 1-14 fused to ABLlexons 2-11; also termed b2a2 orb3a2), and P230 BCR/ABL1(BCR exons 1-19 fused to ABLl exons 2-11).

advantage on the cells, namely their leukemic phenotype. However, many recombinogenic motifs and repetitive elements have been reported to coincide with the breakpoints in ABLJ and BCR and have, hence, been suggested to increase the likelihood of recombination between these two genes, such as Alu repeats, heptamer/noname r sequences, and translinbinding motifs which could facilitate DNA recombination (de Klein et al., 1986; Chen etal., 1989;Sowerbyetal., I993;Chissoeetal., 1995; Jeffs et al., 1998,2001), but so far no clear-cut evidence has been forthcoming for a critical role of such sequences in the generation of the t(9;22). Because a prerequisite for joining of BCR and ABLl is a spatial proximity of the broken chromosome ends, the position of 9q34 and 22ql 1 relative to each other in the nucleus has also been investigated. Evidence in favor of such proximity has indeed been obtained, suggesting that the formation of translocations also in part is determined by higher order spatial organization of the genome (Neves et al., 1999; Kozubek

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et al., 1999; Roix et al., 2003). Yet another featurethat may prove importantwas the identificationof a 76 kb duplicatedgenomicregion(duplicon)presenton 9q34 ( 1.4 Mb5’ of ABLI) and on 22qll (150kb 3’ of BCR) that could facilitate a mitotic chromosomal exchange by bringing two genes into proximity of each other (Saglio et al., 2002). Subsequentrandombreakageandjoining of the two genes, possibly guided by repetitive elementsor sequencemotifsin thevicinityof thebreakpoints,followedby selectionforcells producing in-frame BCWABLI fusion products, could be a mechanism by which a combinationof differentfactorswould resultin a clonal expansionand clinically manifest CML.Itis in thiscontextalso interestingto note thatby usinghighlyoptimizedandsensitive RT-PCRassays,it hasbeen demonstratedthatapproximately25-30% of healthyindividuals have detectableP2 10 BCWABLI fusion transcriptsin their peripheralblood (Biernaux et al., 1995;Bose et al., 1998). This suggestsnot only thatthe frequencywith which BCW ABLl recombinationtakes place in the normalhematopoieticsystem is high, providing circumstantialevidence for the view that the recombinationis somehow facilitated by sequencemotifs or higherorderspatialorganization,but also thata BCWABLIrecombination has to take place in a particularlyprimed early hematopoieticprogenitorcell for clonal expansionto ensue. Following the formationof the t(9;22) and the fusion of the BCR andABLI genes at the DNA level, transcriptionand splicingwill producean mRNA,approximately8.5 kb in size, in which BCRexons 1-12or 1-13 becomefusedtoABLexons2-1 I (b2a2orb3a2junction) (Fig. 7.2). Even in cases whereexon l b or l a of ABLI is includedin the chimericgene and theprimarytranscript,it is typicallysplicedout in the matureBCWABLImRNA.The 8.5 kb mRNA is translatedinto a 210-kDa BCWABLl fusion protein(P210) consistingof amino acids 1-902 derivedfrom BCR (or amino acids 1-927 if M-bcrb3 is included),linked to 1096 residues of ABLl. The reciprocal chimeric ABLl/BCR gene on the derivative chromosome9 is also transcribedin approximately50-7096 of CMLcases, but its possible pathogeneticrole in CML, if any, remainsunclearand no clear correlationto prognostic featureshas been demonstrated(Melo et al., 1993, 1996; de la Fuenteet al., 2001). At theproteinlevel, theP210 andP230 BCWABLchimerasincludeimportantfunctional domainsderivedfrom the normalBCR and ABLl proteins.Althoughthe precise normal cellularfunctionof the 160-kDa BCR proteinis still largely unknown,it is known that it containsan oligomerizationdomainanda serine/threoninekinaseactivityencodedby exon 1 (Maruand Witte, 1991), a segmentlocatedin the centralpartthatcarriesa Rho guanine nucleotideexchange factor (RHO-GEF,also designatedDBL-like) domain,a pleckstrin homology (PH) domain, and a RAC-GAP domain at the C-terminalend (Diekmann et al., 1991; Deininger et al., 2000). Both P2IO and P230 fusion proteins contain the RHO-GEFand PH domains,whereasP230 also harborsa calcium-dependentlipid-binding domainas well as a truncatedRAC-GAPdomain (Barnesand Melo, 2002). The protein domainsof the nonreceptortyrosinekinase ABLl included in the P210 and P230 BCW ABLl comprisethe SRChomologydomainsSH2 andSH3,a tyrosinekinasedomain(SH 1), as well as DNA- and actin-bindingdomains. In contrastto the normalABLl protein,which predominantlyis locatedin the nucleus, the BCWABLI fusion protein is located in the cytoplasm and displays a deregulated andconstitutivetyrosinekinaseactivity,facilitatedby theoligomerizationdomainencoded by the first exon of BCR (Lug0 et al., 1990; McWhirterand Wang, 199I ) . Duringrecent years,severalstudieshave identifieda numberof signalingpathways(e.g., the JAWSTAT, RAS, and PI-3 kinase pathways)and proteins(e.g., CRKL,FAK, and P X N ) that become activated or phosphorylatedby BCWABLI. The molecular signaling patternthat has

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emerged is highly complex, but it ultimately results in enhancedcellular proliferation, inhibitionof apoptosis,and alteredadhesion propertiesthat are characteristicfeaturesof CML cells (for excellent reviews, see Deiningeret al., 204)0, Melo and Deininger,2004; Ren, 2005). Themost commonlyused approach.tostudyPh-positiveleukemiasin animalshasbeen to expressthe differentBCWABL1 fusiongenes in mice througheithertransgenicor retroviral transductiontechniques.Early studies in the 1990s used retroviraltransductionof BCW ABLl into mouse BM cells, followed by BM transplantation into syngenic mice. Some of these mice developed a myeloproliferativedisease closely resembling human CML, whereas others displayed a disease distinct from CML, involving lymphoid, erythroid, mast cell, or macrophagelineages (Daley et al., 1990; Elefanty et al., 1990; Kelliher et al., 1990; Elefanty and Cory, 1992; Gishizky et al., 1993). Although these important studiesconfirmedthe oncogenic activityof BCFUABL,they did not faithfullyrecapitulate human CML. However, subsequentimprovementsin retroviralvector design and transductionprotocolsenabledtheestablishment,with a very high efficiency,of mice developing a myeloproliferativedisorder that resembles CML CP (Pear et al., 1998; Zhang and Ren. 1998; Li et al., 1999). The transgenicapproachwas initiallyhamperedby the fact thatBCWABLl constructs, whose expression was controlled by the BCR promoter,caused embryonic lethality (Heisterkampet al., 1991). Subsequently, several investigatorsdemonstratedthat the disease phenotypesin transgenicP210 BCWABLI mice were dependenton the expression patternandthecell-typespecificityof the regulatoryelementsusedto driveexpressionof the fusion genes (Vonckenet al., 1995; Hondaet al., 1998;Huettneret al., 2000,2003). Using regulatoryelements from the human CD34 locus, Huettneret al. (2003) were able to establisha mouse line in which P210 BCWABLI could be expressedin an induciblemanner. These mice developeda myeloproliferativesyndrome,but with a preferentialexpansionof the megakaryocyticlineage causing thrombocytosis.By targetingthe expressionof P210 BCWABLI to the stem and progenitorcells of murine BM, the same group recently establishedmice in which inductionof BCWABLI resultedin neutrophiliaandsplenomegaly, with some animals also developing a B-cell lymphoblasticdisease reminiscentof humanCML CP followed by a lymphoidblast crisis (Koschmiederet al., 2005). In summary,althoughwe do not know how the t(9;22) or the BCWABLI fusion arises, detailedmoleculargenetic and functionalstudies have resulted in profoundinsights into how BCWABLI elicits a leukemicresponse,with animal studies having shown that the fusiongene is capableof initiatinga diseaseclosely recapitulatinghumanCML.As will be discussed furtherbelow, the introductionof imatiniband otherTKI has not only revolutionized the treatmentof CML but has also opened up new avenues throughwhich an increasedunderstandingof BCFUABL1 -mediatedleukemogenesisis likely to be acquired.

TREATMENT AND DISEASE MONITORING IN CML Treatmentof CMLhas changeddramaticallyoverthe lastdecades.Therapywith busulphan was initiatedin the 1950sbutwas thenreplacedby hydroxyurea,followedby introductionof IF"-cx in the early 1980s. the firstdrugto inducea markedcytogeneticresponsein CML patients (Goldman,2007). Treatmentwith curativeintentionwas subsequentlyrealized through allogeneic stem cell transplantation (SCT)in the 1980s, and this became the treatmentof choice for youngerpatientswith HLA-matcheddonors.The therapyhas since

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been revolutionizedby the arrivalof imatinib(imatinibmesylate,formerlyST1571) thatwas firstused in clinicaltrialsstartingin 1998, in which its limitedtoxicityandabilityto induce hematologicandcytogeneticresponsewere firstestablished(Drukeret al., 2001). Imatinib has now emerged as a front-linetherapyin the treatmentof CML patientswith increased survival advantages compared to previously available treatment regimens (O’Brien et al., 2003; Drukeret al., 2006; Roy et al., 2006). In a 5-year follow-up of patients receiving imatinib(the IRIS study), the estimated cumulativebest rates of a complete hematologicresponse (CflR) or a complete cytogenetic response(CCR) were 98% and 87%, respectively,and the estimatedoverall survivalof patientswho receivedimatinibas initial therapywas 89% at 60 months(Drukeret al., 2006). The imatinibcompound binds to the ATP-bindingpocket of the ABLl domain and stabilizes the inactive, non-ATP-bindingconformationof BCRlABLI. This blocks the tyrosinekinase activity and inhibitsboth BCWABLI-mediatedautophosphorylation and substratephosphorylation,resultingin abrogateddownstreamcell signalingand reduced proliferationof the BCWABLf -positivecells (Deiningeret al., 2005). Althoughimatinibis highly specific for ABLl , the KIT, PDGFR,and ARG tyrosine kinase activitiesare also suppressed(Deiningeret al., 2005). Despite the highly promising results of imatinib treatment,problems related to the occurrenceof ABLl kinase mutationsand its modest activityin more advancedphases of CML still remain. So far, more than 50 differentmutationswithin the kinase domain of BCWABLI have been described with the frequency varying dependingon the Ch4L phase and definitionof resistance(Deiningeret al., 2005; Quintas-Cardama et al., 2007). At the proteinlevel, such mutationsgenerally result in an inability of ABLl to adopt the inactive conformationto which imatinib binds. The most well-known and clinically relevantmutationis T3151, in which threonineis replacedby an isoleucine at aminoacid position 315 in the ABLl part.This mutationis highly resistantto imatiniband also to second-generationTKI (see later), whereas other mutationsdisplay various degrees of resistance to imatinib that can be overcome with newer TKI (Deininger et al., 2005; Quintbs-Cardamaet al., 2007). Evidence has also been forthcoming that in some patients,mutationsidentified at relapse were alreadypresent in samples taken priorto imatinib therapy (Deininger et a]., 2005). This suggests that such mutations are constantlyformed in BCRfABLl-expressingcells and that they only become selected once imatinibtreatmentis introduced. The occurrenceof resistance toward imatinib has promptedthe development of a plethoraof novel inhibitorsthatare currentlybeing tested in preclinicaland clinical trials (Quint&-Cardamaet al., 2007). The second-generationkinase inhibitorsdasatinib(formerly BMS-354825) and nilotinib(formerlyAMN107) have shown promisingresultsin patients with imatinib-resistantdisease (Kantarjianet al., 2006; Talpaz et al., 2006). Dasatinibhas been shown to be a more potent inhibitorthan imatinib,possibly due to its dualinhibitoryeffectson boththe ABLl andSRCkinasefamilies.Dasatinibalsobindsto both the active and inactive conformationsof the ABLl kinase domain (Lombard0 et al., 2004; Shah et al., 2004). Nilotinib, like imatinib,bindsto the inactiveconformation of ABLl but is more potentand shows both higherbindingaffinityand selectivity for the ABLl kinase(Weisberget al., 2005). Althoughdasatiniband nilotinibhave been shownto be effective againstmost imatinib-resistant mutationsin clinical trials,the TI351 mutation remainsresistant(Kantarjianet al., 2006; Talpazet al., 2006). Furthermore,even though dasatinibis moreeffectivein targetinganearlierBCWABLf -positiveprogenitorpopulation, quiescent primitive CML cells still remain viable (Copland et al., 2006). Thus, the

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persistenceof quiescent CML stem cells, which are insensitive to imatiniband secondgeneration TKI, offers a source for reestablishmentof the disease once treatmentis discontinued,andprovides,togetherwith the developmentof resistance,majorchallenging problemsfor diseaseeradication(Jianget al., 2007; Jergensenand Holyoake,2007; Savona and Talpaz,2008). Once treatmentwith imatinibor otherTKI has been initiated,regularcytogenetic and molecularmonitoringof the BCWABLI fusion transcriptwith real-timequantitativePCR should be performed according to recently published recommendations(Baccarani et al., 2006; Goldman,2007; Hehlmannet al., 2007). In short,cytogeneticresponseshould be checkedevery 6 monthsuntil completecytogeneticremissionhas been achieved.Once this has been accomplished,yearly monitoringby BM aspirationshould be performedto excludemarrowdysplasiaor theemergenceof cytogeneticchangesin Ph-negativecells (see later).If a completecytogeneticremissionhas been obtained,molecularresponseshouldbe evaluatedevery 3 months.Mutationanalysisis warrantedif the treatmentfails, the response is unsatisfactory,or the level of fusion transcriptincreasesin repeatedassays.Dependingon the resultsfromrepeatedmonitoring,changesin the dose of imatinibora shiftin therapyto second-generationTKI may be advocated (Goldman, 2007; Hehlmann et al., 2007). Overall, while therapeuticand diagnostic progress has made treatmentof CML more effective, it has also become more challenging to keep pace with the optimal clinical managementand laboratorypracticefor monitoringsuch patients.

CYTOGENETIC EVOLUTION IN Ph-POSITIVE CML Becauseof the clinical courseof CML, with its CP eventuallyprogressinginto an AP and BC, CML has become a well-studied model for the multistepnatureof carcinogenesis. Althoughit is well establishedthatthe BCWABLI fusion gene is criticalforthe initiationof CP,andin most instancesalso for the maintenanceof BC, less is knownaboutthe underlying cellularand genetic events leading to disease progression.However,a growing numberof studies have suggested that BCWABLI-expressingcells display failures in genomic surveillanceandDNA repair,somethingthatcould play an importantrolefortheoccurrence of secondarygenetic changes (Melo and Barnes,2007). Below, we review the currently availabledata regardingcytogenetic and moleculargenetic changes that are observedat disease progressionof CML. Even though occasional CML cases harborother changes early in the disease, as mentionedabove, the t(9;22) typically remainsthe sole abnormalitythroughoutmost of the CP. When disease progressionoccurs, however,60-80% of cases develop additional chromosomeaberrations.These secondarychanges sometimes precede thehematologic and clinical manifestationsof a more malignantdisease by several months and thus may serve as valuableprognosticindicators.As will be discussedfurtherbelow, the treatment given duringCP also influences the patternof secondarygenetic changesobserved. Early cytogenetic investigationsin the prebandingera indicatedthat the karyotypic abnormalitiesoccurringin excess of the Ph chromosomewere nonrandom,an observation that was corroboratedwhen the variousbandingtechniquesbecame available(Johansson et al., 2002). Based on a series of 10 patientsand on a review of 57 publishedcases with additionalcytogeneticaberrations,Mitelmanet al. (1 976) identifiedan extraPh, 8, and i( 17q)as the most commonsecondarychanges,beingpresentin approximately90%of cases with additionalabnormalities.These changes were referredto as constitutingthe “major

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route”of clonalevolution,whereasotherless frequentlyobservedchangeswere designated “minor route” aberrations. Secondarychromosomeaberrationshave now been reportedin more than 2500 CML, cases (Mitelmanet al., 2008). The patternis clearly nonrandom,with the most common chromosomalabnormalitiesbeing +8 (34% of cases with additionalchanges), +Ph (31%), i(17q) (20%),and 19 (13%).All otheradditionalchromosomalchangesoccurin less than lo%,the most frequentbeing -Y, 2 1, -7, 17, and - 17;the sameaberrations were also the most common in a survey of 180 CML cases with varianttranslocations (Johanssonet al., 2002). Apartfroma slightlylowerprevalenceof 8, Ph,i( 17q), 19, -17, and 14 and a higher frequencyof 13q- in CML with varianttranslocations,no clear-cutdifferencesbetween the two groupscould be discerned.CombiningCMLcases with standardand variant translocations,the most common additional chromosomal changes in the study by Johanssonet al. (2002) were + 8 (30%), +Ph (30%). i(17q) (20%), 19 (12%), -Y (8%of males), 21 (7%),and -7 (5%). Using acut-off value of 5%, they proposedto expand the majorevolutionaryroute to include all these changes. Manyof the observedsecondarychangesarefoundin various combinations.Hashimoto et al. (1990) used hierarchicallog-linearmodelsto show thatsome combinations( 8 and i( l7q), 8 and 19, and 19and Ph) arepositively associated,whereasothers(i( I7q) and 19 and i( 17q) and Ph) are negativelyassociated.This suggeststhatthe selective advantageof a secondarychange seems to vary dependingon other alterationsalready presentwithinthe cell. Thereis also evidence suggestingthatthe most common secondary abnormalitiesoccur in a step-wise,well-orderedmanner,with a frequentpathwaystarting with i( 17q), followed by 8 and Ph, and then 19 (Johanssonet al., 2002). As is evident from the compilationabove, the greatmajorityof the secondarychanges observedaregenomicallyunbalanced,thatis, trisomies,monosomies,anddeletions.There arenotableexceptionsto this pattern,however;severalbalancedchangestypically foundin AML, for example, inv(3)(q21q26)/t(3;3)(q21;q26), t(3;21)(q26;q22), t(7;I l)(pl5;p15), t(8;21)(q22;q22),t( 15;17)(q22;q21),and inv( 16)(p13q22), have also been observed at disease progressionof CML (Mitelmanet al., 2008). As describedin Chapter5, these changes in AML are associatedwith quite specific phenotypicand clinical featuresand should,probably,in CML be seen as second primarychanges ratherthan as “ordinary” secondary changes. Notably, as exemplified by t(15;17) and inv(l6), the morphologic featuresof CMLBC harboringsuchchangesresemblethosefoundin de now AMLwith the same balancedabnormalities(Mitelmanet al., 2008). The phenotypicimpactof the more common secondaryaberrationsin CML. that is. if certainchanges are associated with a myeloidor lymphoidBC, is unclear.Whenreviewingthe literature,Johanssonet al. (2002) found that the only significantdifferencesin cytogeneticevolutionpatternswas a higher incidence of i(17q) in myeloid BC and a higher frequencyof monosomy 7 and hypodiploidy in lymphoid BC. There were no significant frequencydifferencesof balanced abnormalitiesin additionto t(9;22)betweenmyeloid and lymphoidBC. Notably,however, whereas most balanced aberrationsin myeloid BC are the well-known AML-associated translocationsmentioned above, balanced changes in lymphoid BC are preferentially nonrecurrent andnot characteristicALL-associatedtranslocations(Johanssonet al., 2002). The type of treatmentgiven during CP seems to influence the patternsof secondary abnormalitiesobservedduringAP andBC. Forexample, 8 is significantlymorecommon afterbusulphantreatmentas comparedto CMLtreatedwith hydroxyurea(Johanssonet al., 2002). Treatment with TFN-a is associated with an aberrantkaryotypic evolution patterndisplayingincreasedfrequenciesof unusualsecondarychanges,that is, non-major

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route abnormalities,and divergentclones, cell populationswith unrelatedaberrationsin additionto t(9;22) (Johanssonet al., 1996,2002; Maloisel et al., 1997). The emergenceof Ph-negativecells with clonal chromosomalchanges,mainly trisomy8, has been observed aftertreatmentwith IFN-a(Johanssonet al., 2002), a findingreminiscentof recentreports following treatmentwith imatinib(see later).In addition,severalstudieshaveshownthatthe cytogeneticevolutionpatternis quite distinctafterallogeneic SCT (Karrmanet al., 2007); majorrouteabnormalitiesareless frequent,butinstead,the changesobservedare seemingly random,structurallycomplex, andsometimestransient,with a high frequencyof balanced translocationsand divergent clones (Karrmanet al., 2007). The occurrence of this “unconventional”cytogenetic evolution pattern following allogeneic SCT has been suggested to be caused by the conditioningregime, that is, it arises as a consequenceof the clastogenic effect of total body irradiation and/or alkylating agents (Alimena et al., 1990; Offit et al., 1990; Sessaregoet al., 1991; Bilhou-Naberaet al., 1992; Shah et al., 1992; Chase et al., 2000). However,comparingthe cytogeneticevolutionpatternin CMLpatientstreatedwith autologousor allogeneic SCT,Karrman et al. (2007) foundthat balancedchangesweremorecommonafterallogeneicSCTandthatthecytogeneticfeatures after autologousSCT were more similarto the ones observed in non-transplantedCML patients.Becausethe conditioningregimensaresimilarin the two settings,it was suggested thatthe atypicalevolutionpatternobservedafterallogeneicSCTrathercouldbe a resultof an alteredBM microenvironmentandorthe immunosuppressiongiven to such patients. Most patients who have received treatmentwith imatinibso far remain in complete cytogeneticremission,butwhen cytogeneticchangesappearin Ph-positivecells they seem to follow the majorrouteof evolution.Forexample,Schochet al. (2003) foundthatduring treatmentwith imatinib, 18 of 140 (13%) patients developed additionalchromosomal abnormalities.Eleven of these patientsdisplayedone to threeof the majorrouteabnormalities Ph (n= 5), 8 (n= 8) or i( I7q) (n= 2), whereas the remainingcases mainly showed uncharacteristiccytogeneticchanges,of which none were recurrent.Corteset al. (2003) reportedthatamong377 patientswithoutadditionalcytogeneticchangesat the start of imatinib therapy, 32 (8%) later developed additional chromosomalabnormalities, including 8 (n= I6), chromosome 5 or 7 abnormalities(n= 8), and others (n= 8). Studyingpatientson dasatinibtherapy,Fabariuset al. (2007) observedadditionalchromosomal aberrationsin Ph-positive cells in six out of 71 patients (8%), with major route abnormalitiespresent in three cases. Taken together, theavailabledata suggest that the cytogeneticevolutionpatternin Ph-positivecells of CMLpatientstreatedwithTKI seemsto follow the majorrouteof evolution.Additionalstudiesareneededbeforereliablefrequency estimatescan be obtainedand, if novel recurrentchanges are detected,they may provide importantinsights into possible genetic mechanisms underlying the development of resistanceto treatmentwith TKI. Whatis theclinical significanceof a clonalcytogeneticchangedetectedwhile a patientis undertherapywith imatinibor otherTKI? It has been shown that such changes may be transient,disappearingwith continuedorincreaseddoses of therapy,particularlyin patients who initiallyhad achieveda completecytogeneticresponse,butthatthey may also persistas a small subcloneor become a predominantclone (Corteset al., 2003). Thus,furtherstudies are clearly needed to clarify the prognosticsignificanceof such changes. Anothercytogeneticphenomenonthathas attractedconsiderableinterestin the present era of imatinibtreatmentis the observationof clonal cytogeneticchanges in Ph-negative cells. The estimatesof such abnormalitiesin largerseriesarein the orderof 2-1 7%(Bumm etal.,2003;Medinaetal.,2003;ODwyeretal.,2003;Terreetal.,2004;Bacheretal.,2005;

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Abruzzese et al., 2007;Deiningeret al., 2007;Jabbouret al., 2007). The most common changesobservedin the Ph-negativecells are -7, 8, -5, and -Y.Suchchangesarealso frequent in myelodysplasticsyndromes (MDS) and AML, something that has raised concernsabouttheirclinical implications.Thereare now close to 20 case reportsof MDS or AML developingin imatinib-treated patients,carryingmainlymonosomy7 or trisomy8 in their Ph-negative cells (-Y has so far not been described),while at the same time remainingin complete cytogenetic remission regardingt(9;22)-positivecells (Mitelman et al., 2008).The frequencywith whichovert MDS/AMLdevelopsin suchpatientsis in the orderof 2-lo%, emphasizingthe importanceof continuedcytogeneticmonitoringof CML patients receiving imatinib (Kovitz et al., 2006; Deininger et al., 2007). While the occurrenceof clonal cytogenetic changes in Ph-negativecells may justify regular cytogenetic analysis and BM examination,currentrecommendationssuggest that, with the possible exception of monosomy 7, such findings should not lead to any immediate treatmentinterventionsin the absenceof morphologicevidence of MDS/AML(Deininger et al., 2007). The reason(s)forclonal cytogeneticchangesin Ph-negativecells is unknown.Although initiallyonly reportedin patientsthathad receivedtreatmentwith otherdrugsthan imatinib, clonal evolutionin Ph-negativecells has now also been observedin largerseriesof patients receivingthis drugonly (Jabbouret al., 2007).This suggeststhatit is unlikelythatprevious treatmentwith, for example, hydroxyureaor IFN-acould have induced the secondary genetic changes observed in Ph-negativecells. Anotherhypothesisis based on the early observationsthat the distributionof glucose-6-phosphatedehydrogenaseisoenzyme patternsin Ph-negativeB-cell lines derivedhorn CMLpatientswas skewedtowardthe pattern observed in CML cells, suggesting that the t(9;22) arises in a populationof clonal Phnegativecells (Fialkowet al., I98i ;Raskindet al., 1993). If this two-stepmodel of CML is true, then the emergenceof cytogeneticchanges in Ph-negativecells could be explained througha selectivesuppressionof thePh-positiveclonethatwould allow an expansionof the “first hit” clone. However, it has been demonstrated,by the use of X chromosome inactivationstudies, that imatinibrestores a polyclonal bone marrowpatternin female patientsundertreatment(Bummet al., 2003),makingthis mechanismless likely, although smallermonoclonal cell populationsprobablywould escape detectionwith the methods used.A thirdpossibilitywouldbe thatimatinibby itself inducesorfavorstheacquisitionand selectionof clonalcytogeneticchangesin Ph-negativecells (Bummet al., 2003).Thiscould be explainedby the(side) effect of imatinibon the normalABLl protein,which is involved in DNA damageandrepaircontrol(Wang,2000). Althoughclonal cytogeneticchangesin theBM of patientstreatedwith imatinibfor otherdisorders,such as gastrointestinalstromal tumors(also referredto as GIST), have not, to the best of our knowledge, been reported, inhibitionof normal ABLl could favor the selection of cells with randomchanges, for example,monosomy 7 or 8,in particularwhen hematopoiesisis being restoredfrom a limited pool of Ph-negativestem cells.

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MOLECULAR GENETIC EVOLUTION IN Ph-POSITIVE CML Severalmoleculargeneticchangeshavebeen identifiedduringdiseaseprogressionof CML, but apartfrom quite frequentchanges now having been identified in lymphoid BC (see later),no single or universalabnormalityhas been shownto be the criticalgeneticeventfor the transitionof CPintoBC. It is equallyunclearif the secondarymoleculargeneticchanges

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occurat the level of the t(9;22)-harboringHSC or in a more matureprogenitor;supportfor the latter,at least in myeloid BC, hasrecentlybeen forthcoming(Jamiesonet al., 2004). The moleculargeneticchangesobservedcan-somewhat simplistically-be dividedinto those associatedwith identifiablechromosomalchanges, that is, they arethe moleculargenetic consequencesof the majorand minorrouteabnormalitiesdiscussedabove, and those that are cytogeneticallycryptic. 8, i( 17q), and Even as regardsthe most common secondarycytogenetic changes+ Ph-the molecularconsequencesremainlargelyunknown.Forexample,the functional outcomeand the pathogeneticeffects of trisomy8, which is foundas a sole abnormalityin 5-10% of cytogenetically abnormalAML and MDS, are still unclear (Paulsson and Johansson,2007). It has been suggested that the MYC gene in 8q24 could play a role because it has been shown to be amplifiedand upregulated ina few cases of CML BC (Karasawaet al., 1996; Beck et al., 1998; Jenningsand Mills, 1998). Moreover,in vitro studieshave shownthatMYC is importantfor mediatingthe transformingeffects of BCW ABLl (Sawyerset al., 1992)and,morerecently,BCIUABLIwas shownto upregulateMYC at the translationallevel (Notariet al., 2006). However, while MYC may have a role in mediatingthe effects of BCFUABLI , it seems unlikelythat 8 wouldbe the mechanismby which this is accomplished,not leastbecauseglobalgene expressionstudiesof hematologic malignancieshave demonstratedthat trisomiesof chromosome 8, as well as of other chromosomes,lead to a generalupregulationof a large fractionof genes located on such additionalchromosomes(Virtanevaet al., 2001; Ross et al., 2003; Anderssonet al., 2005). 3 been Mutationsin the well-known tumorsuppressorgene (TSG) TP53 in 1 7 ~ 1 have detected in approximately10%(0-30%) of CML BC. This gene is an attractivecandidate for a role in disease progressionbecauseof the frequentloss of 17p due to i( 17q), -17, or other changes resultingin loss of materialfrom 17p (Johanssonet al., 2002; Melo and Barnes,2007). However,no coding TP53 mutationswere detectedin a seriesof CML BC and other hematologic malignancieswith i(17q), suggesting that other TSG on 17p or, alternatively,gain of 17q materialcould be the pathogeneticallyimportantevent (Fioretos et al., 1999). As to the mechanismby which the i(17q) is formed, some data have been forthcoming suggesting that genomic architecturalfeatures may be critical (Barbouti et al., 2004). The i(17q) has been shown not to be a true isochromosomebut ratheran isodicentric abnormalitywith the breakpointsoccumng in 17pl I , either in the very pericentromericregion or in a genetically unstableregion denoted the Smith-Magenis syndrome (SMS) common deletion region (Chen et al., 1997; Fioretos et al., 1999; Scheurlenet al., 1999). Thus, the i( 17q) shouldformallybe designatedidic(l7)(pl I). The breakpointregion in 17plI was shown to display a complex genomic architecture characterizedby large(38-49 kb), pdindromic,low-copy repeats.Palindromicsequences, or invertedrepeats,are well-establishedhot spots of genomic instability,and the identification of such elements at the 17pl1 breakpoint,perhapsin combinationwith a dysfunctional double-strandbreakrepairpresent in BCWABLl-expressingcells (see above), has been suggestedto be a critical factortriggeringi( 17q) formation(Barboutiet al., 2004). While it seems naturalto conclude that the presence of an extra Ph duringdisease progression results in an increasedexpressionof the BCWABL1 fusion gene, no large studies addressingthis issue have been reported.However, it has been shown that the expressionlevel of BCWABLI increasesat AP andBC, suggestingthatthis may be a critical factor in disease progression (Melo and Barnes, 2007). As to the other major route 19, and 21, no molecularcorrelateshave so far emerged. abnormalities,that is, -7, It was recently shown that among one CML CP and 13 BC sampleswith trisomy 21, six

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(43%) displayed mutationswithin the DNA-binding domain of RUNXI (also known as AMLI) at 21q22, of which two also harboreda t(1;21)(p36;q22)and a RUNXUPRDMI6 fusion gene, leadingto “biallelic” RUNXI mutations(Roche-Lestienneet al., 2008). Thus, RUNXI mutationsseemto be importantalterationsassociatedwith CMLBC, particularlyin cases showing 21, with experimentaldataalso suggestingthatthiscould be a mechanism by which CML BC cells become resistantto imatinib(Miethinget al., 2007). In contrastto our limited understandingof the pathogeneticconsequencesof the major routeabnormalities,the molecularconsequencesof some rarelyobserved,but nevertheless highly informative,cases of balanced chromosomal changes in BC are more easily understood.Thus, in rare instancesof CML BC (see above), balancedchanges, such as inv(3)(q21q26), t(3;21)(q26;q22), t(7;1 l)(p15;p15), t(8;21)(q22;q22), and inv(16) (p13q22),are observed,all resultingin the formationof chimericfusion genes (Mitelman et al., 2008). A notablefeatureof severalof thesechanges-t(3;2I), t(8;2t), andinv(16)-is thatthey rearrangeeitherRUNXI or CBFB. encodingthe heterodimericcore bindingfactor (CBF) complex (Mikhailet al., 2006). emphasizingthe importanceof alterationsin this regulatorycomplex in CMLdisease progression.Anotherrecurringtheme is the involvementof homeoboxgenes, illustratedby the identificationof some rarelyoccurringchanges at diseaseprogression:t(7;1 I)(p15;p 15), resultingin NUP98/HOXA9 andNUP98JHOXAII fusions(Borrowet al., 1996;Nakamuraet al., 1996;Fujinoet al.. 2002), the cytogenetically cryptict(7;17)(pl5;q23)thatformsa MSI2/HOXA9 chimera(Barboutiet al., 2003), andthe t(1;l l)(q23;p15) fusing NUP98 with the homeobox gene PMXl (Nakamuraet al., 1999; Roche-Lestienneet al., 2008). The latter changes suggest that deregulationof genes belongingto the HOX family could also be a factor in disease progression. Several moleculargenetic changes not correlatedto any of the well-known secondary cytogeneticchanges,but ratherhaving been investigatedbecauseof theirgeneralinvolvement in tumorigenesis,have also been identifiedduringdisease progression.Such studies (too many to be cited individually,but summarizedin the referencesto follow) includethe RBI gene, whose expressionat the proteinlevel has been reportedto be absentin cases with megakaryoblasticBC but not in CML with other BC phenotypes, the various RAS oncogenes that only occasionally seem to be mutated, loss of imprintingof the ZGF2 gene, hypermethylation of the calcitoningene, methylationof the proximalpromoterof the ABLI gene, and increased telomerase activity (Johanssonet al., 2002; Calabrettaand Perrotti,2004, Melo and Barnes,2007). However, as of yet, none of these changeshave convincingly been demonstratedto constitutecritical alterationsunderlyingthe disease progressionof CML.Mutationalanalysesof 85 unselectedCML BC samples,focusingon alterationsin key transcriptionfactorsinvolved in regulatingnormalhematopoiesis(PUI, CEBPA, GATAI-3, RUNXI, CBFB, MYB, K S B P , TP53, NRAS, and KRAS),identified novel gain-of-functionmutationsin GATAZ in 9 of 85 (10%) cases and confirmed the presenceof mutationsin RUNXI (13%) and in TP53 (4%) (Zhanget al., 2008). Notably, cases with mutationsin GA TA2 preferentiallydisplayeda myelomonocyticBC phenotype, with the mutationbeing associatedwith an inferioroutcome when comparedto RLJNXl mutatedcases and those lackingmutations(Zhanget al., 2008). Deletionsof CDKN2A (also referredto as “ ~ 1 6 ”have ) been detectedin about 30% (14 of 47 cases) of lymphoidBC, whereas such mutationsare rare in myeloid BC (Serra et al., 1995; Sill et al., 1995; Hernindez-Boludaet al., 2003). It should,in this context,be emphasizedthatsome critical factorsfor disease progressionmay not be detectableas mutationsat the DNA or mRNA levels, as recentlydemonstratedfor CEBPA, which is a criticalregulatorfor granulocytic differentiation.While CEBPA mutationsareobservedin approximately10%of AML with

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normalkaryotypes(Pabstet al., 2001 ;Gombartet al., 2002), no mutationswere detectedin 95 CML BC samples (Pabstet al., 2006). However, both experimentaldata and studies performedon CMLBC sampleshave suggestedthatBCWABL1, throughthe RNA-binding proteinhnRNPE2,inhibitsthe translationof CEBPA,thusprovidinga mechanismby which CEBPAmay be involved in disease progression(Perrottiet al., 2002; Changet al., 2007). Genome-widemeasurementsof DNA copy numberchangesand transcriptionalalterations have recentlystartedto revealnovel insightsinto mechanismsunderlyingthe disease progressionof CML. Studies using BAC arrayswith a 1 Mb resolutionhave disclosed a numberof novel andrecurrentcopy numberchanges,includinggains at 8q24 and losses at 5q22-31 and8p21 ;theseaberrationswereobservedin two independentstudies,althoughno novel genes could be convincingly identified as pathogeneticallyimportant (Hosoya et al., 2006; Brazmaet al., 2007). Interestingly,using higherresolution(250K) SNP arrays, it was recentlydemonstratedthat36 of 43 (84%)Ph-positiveALL and4 of I5 (27%)CML BC samples harboreddeletions in the IKZFI gene encoding the transcriptionfactor IKAROS that is critical for normal lymphoid differentiation(Mullighan et al., 2008). Overall,0.5 copy numberchangeswere observedperCMLCP sample,whereasabouteight alterationswere identifiedon averagein each CMLBC sample.Notably,two out of three lymphoid BC samples displayedZKZFl deletions, suggestingthat loss of IKAROS may contributeto the arrestedB-lymphoidmaturationin lymphoidCML BC as well as in Phpositive ALL (Mullighanet al., 2008). Frequentcodeletionsof PAX5 and CDKN2A were also observed in BCWABLI-positiveALL, indicatingthat several changes are needed beforeovertdisease develops.Global gene expressionstudiescomparingCMLCPand BC samples have identified a vast number of genes becoming deregulatedupon disease progression.The largest study so far examined 91 cases of CML (42 CP, 17 AP, and 32 BC) and identified3,000 genes thatwere significantlyassociatedwith the diseasephase of CML(Radichet al., 2006). It was concluded,basedon the gene expressionpatterns,that the disease evolution in CML is a two-stage ratherthan a three-stage process, as the deregulatedgene expressionpatternin AP stronglycorrelatedwith the patternobservedin BC. Moreover,several genes belonging to the WNT/P-cateninpathway were found to become deregulatedtogetherwith several additionalgenes (e.g., JUNB, FOS, WT1, and SOCS2) previously implicated in BCWABLI -mediated leukemogenesis(Radich et al., 2006; Melo and Barnes, 2007; Radich,2007; Hikansson et al., 2008). As evident from the above-mentioneddata,no single cytogeneticor moleculargenetic change seems to be responsiblefor disease transformationin CML. Instead,multipleand differentgenetic aberrationsare likely to be requiredfor disease progression.Hopefully, with the introductionof novel technologies,patternsof changesalso at the molecularlevel will be identified, in analogy with the identificationof cytogenetic evolutionaryroutes. While some “molecularroutes”areemerging(e.g., thecommonderegulationof RUNXI in myeloid BC anddeletionsof CDKN2A and IKZFIin lymphoidBC), additionalstudiesare clearlyneeded.At the sametime, it is importantto recognizethat the changesidentifiedare likely to vary in relationto the treatmentgiven duringCP.

SUMMARY The t(9;22)(q34;qlI ) or its varianttranslocations(seen in 5-10%) aredetectedin the great majorityof BM cells frompatientswith CML.A minorityof CMLpatientshavea seemingly normalkaryotypein which the BCR and ABLl genes fuse throughcytogeneticallycryptic

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insertionsor other more complex chromosomalrearrangements. Cytogeneticallycryptic fusionsof BCR andABLI shouldbe actively searchedfor in this diagnosticsettingbecause of the developmentof inhibitors(TKI) that block the tyrosinekinase activity contained within the ABLl part. The introductionof imatinib and other TKI has dramatically improvedthe clinical outcome for CML patients.When tryingto summarizethe clinical importanceof the many cytogenetic and molecular genetic findings discussed in this chapter,it is importantto note thatmuch of ourcurrentknowledgewas accumulatedin the days beforetreatmentwith imatinibor in patientsreceivingsuch treatmentbutwith limited follow-up times. In addition,the evaluationof the clinical significanceof the cytogenetic and moleculargenetic alterationsdetectedat an increasinglyhigherresolutionlevel using newer methodshas barelystarted.It is trulychallengingto keep pace with the many novel genetic findingsthataredescribed,with theirpotentialclinical impact,as well as with the clinical managementof Ch4L patients.All this is strongly dependenton accuratecytogenetic and moleculargenetic diagnostics. Today, the vast majority of patients receiving imatinib treatmentin CP remain in complete hematologic (98%) and cytogenetic remission (87%) with follow-up times of > 5 years. Close monitoringof such patientsis mandatorybecause drug resistancemay develop, which can be detected by increased levels of BCWABLI fusion transcriptsin peripheralblood.Mutationanalysisof ABLl is warrantednot only in such instances,butalso if the initialresponseto treatmentis unsatisfactory,becausechangesin the dose of imatinib ora shift in therapyto second-generation TKImay be advisable.A smallpercentage(around 8%)of the patientsdevelopadditionalcytogeneticchangesin theirPh-positivecells during the course of treatment,seemingly following the majorroute of cytogenetic evolution. Unfortunately,the clinical significanceof such changeshas not been clearly established. While the changes may be transientand disappearwith continuedor increaseddoses of therapy,especially in patients initially achieving a cytogenetic response, they may also persistand become a predominantclone. Moreover,2-1 7% of patientsreceiving imatinib developclonalcytogeneticchanges(mainly-7, 8, and -5) in Ph-negativecells thatalso may pose clinical challenges.Currentfrequencyestimatessuggest thatonly a minorityof such patients (2-10%) develop clinically evident MDS/AML. Thus, while clonal cytogenetic evolution in Ph-negativecells may justify regularcytogenetic follow-up, such findings, with the possible exception of monosomy 7, should not lead to immediate treatmentinterventionin the absence of morphologicalevidence of MDS/AML. In contrastto the high responserates to imatinibin CP, patientsin the more advanced disease stages typicallyexperienceonly brief remissions.Growingevidence suggeststhat quiescent CML stem cells are insensitive to currentlyavailable TKI, which thus may providea reservoirfrom which relapseinto CP and the accumulationof secondarygenetic changesmay occur.A majorfuturechallengein the treatmentof CMLis to developnovel treatmentmodalitiesthatarecapableof eradicatingsuchresidualcells. In the searchforand evaluation of the effectiveness of such novel therapeuticdrugs, it may also become necessary to develop new approachesfor disease monitoring,perhapsby evaluatingthe molecularresponsein the differenthematopoieticcell compartmentsin the BM.

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ACKNOWLEDGMENTS Financial support from the Swedish Cancer Society, the Swedish Childhood Cancer Foundation,and the Swedish ResearchCouncil is gratefullyacknowledged.

REFERENCES

197

REFERENCES Abruzzese E, Gozzetti A, Galimberti S, TrawinskaMM, Caravita T, Siniscalchi A, Cervetti G, MaurielloA, ColettaAM, De FabritiisP (2007): Characterizationof Ph-negativeabnormalclones emerging during imatinibtherapy.Cancer 109:246&2472. Alimena G , De Cuia MR, Mecucci C, Arcese W, MauroF, Screnci M, ManciniM, CedroneM, Nanni M. Montefusco E, Mandelli F (1990): Cytogenetic follow-up after allogeneic bone-marrow transplantationfor Phl-positive chronic myelogenous leukemia. Bone Marrow Transplant 5 : 119-127. AndersonA, Olofsson T, LindgrenD, Nilsson B, Ritz C, Eden P, LassenC, Ride J, Fontes M, Morse H, HeldrupJ, BehrendtzM, MitelmanF, HoglundM, JohanssonB, FioretosT (2005): Molecular signaturesin childhood acute leukemia and their correlationsto expression patternsin normal hematopoieticsubpopulations.Proc Natl Acad Sci USA 102:19069-19074. BaccaraniM, Saglio G, GoldmanJ, HochhausA, Simonsson B, AppelbaumF, ApperleyJ, Cervantes F, CortesJ, DeiningerM, GratwohlA, GuilhotF, HorowitzM, Hughes T, KantajianH, LarsonR, Niederwieser D, Silver R, HehlmannR (2006): Evolving concepts in the managementof chronic myeloid leukemia: recommendationsfrom an expertpanel on behalf of the EuropeanLeukemiaNet. Blood 108:1809-1820. BacherU , HochhausA, BergerU, HiddemannW, HehlmannR,HaferlachT, Schoch C (2005): Clonal aberrationsin Philadelphiachromosomenegative hematopoiesis in patientswith chronic myeloid leukemia treated with imatinibor interferonalpha. Leukemia 19460-463. BarboutiA. Hoglund M, JohanssonB, LassenC, Nilsson PG, HagemeijerA, MitelmanF, FioretosT (2003): A novel gene, MS12, encodinga putativeRNA-bindingproteinis recurrentlyrearrangedat disease progressionof chronic myeloid leukemiaand formsa fusion gene with HOXA9as a result of the cryptic t(7; 17)(p15;q23). Cancer Res 63: 1202-1206. BarboutiA, StankiewiczP, NusbaumC, CuomoC, Cook A, Hoglund M, JohanssonB, HagemeijerA, Park SS, MitelmanF, Lupski JR,FioretosT (2004): The breakpointregion of the most common isochromosome, i( I7q). in humanneoplasia is characterizedby a complex genomic architecture with large, palindromic,low-copy repeats.Am J Hum Genet 74:l-10. BarnesDJ, Melo JV (2002): Cytogeneticand moleculargenetic aspectsof chronicmyeloid leukemia. Acta Haematol 108:180-202. Beck Z, B k s i A, Kov&x E, Kiss J, Kiss A, BaloghE, TelekB, T6thFD, Andirk61,01&E, UdvardyM, Rak K (1998): Changes in oncogene expression implicated in evolution of chronic granulocytic leukemia from its chronic phase to acceleration. Leuk Lymphoma 30:293-306. Bernstein R ( 1988): Cytogenetics of chronic myelogenous leukemia. Semin Hematol25:20-34. Biernaux C, Loos M, Sels A, Huez G, Stryckmans P (1995): Detection of major bcr-abl gene expression at a very low level in blood cells of some healthy individuals. Blood 86~3118-3122. Bilhou-NaberaC, BernardP, MaritG, ViardF, GharbiMJ, Wen Z, LacombeF, BroustetA, Reiffers J ( 1992): Serial cytogenetic studies in allografted patients with chronic myeloid leukemia. Bone Marrow Transplant 4:263-268. BjorkJ, Albin M, WelinderH, TinnerbergH, MauritzsonN, KauppinenT, StrombergU, JohanssonB, Billstrom R, Mikoczy Z, AhlgrenT, Nilsson PG, MitelmanF, HagmarL (2001): Are occupational, hobby, or lifestyle exposuresassociatedwith Philadelphiachromosomepositive chronic myeloid leukaemia? Occup Environ Med 58:722-727. BorrowJ,ShearmanAM, StantonVP Jr,BecherR, CollinsT, WilliamsAJ, DUGI, KatzF, Kwong YL, Moms C, Ohyashiki K, Toyama K, Rowley J, Housman DE (1996): The t(7;11)(p15;p15) translocation in acute myeloid leukaemia fuses the genes for nucleoporin NUP98 and class I homeoproteinHOXA9. Nut Genet 12:159-1 67.

198

CHRONIC MYELOID LEUKEMIA

Bose S, Deininger M, Cora-TyborJ, Goldman JM, Melo JV (1998): The presence of typical and atypical BCR-ABL fusion genes in leukocytes of normal individuals:biologic significance and implicationsfor the assessment of minimal residual disease. Blood 92:3362-3367. BrazmaD, GraceC, HowardJ, Melo JV, Holyoke T, ApperleyJF,NachevaEP(2007): Genomicprofile of chronic myelogenous leukemia: imbalances associated with disease progression. Genes Chromosomes Cancer 46: 1039-1050. Bumm T, Miiller C, AI-Ali HK, Krohn K, ShepherdP, Schmidt E, Leiblein S, FrankeC, HennigE, FriedrichT, Krahl R, Niederwieser D, Deininger MW (2003): Emergence of clonal cytogenetic abnormalitiesin Ph- cells in some CML patients in cytogenetic remission to imatinib but restorationof polyclonal hematopoiesis in the majority.Blood 101:1941-1949. CalabrettaB, PerrottiD (2004): The biology of CML blast crisis. Blood 103:4010-4022. ChanLC, Karhi KK, RayterS1,HeisterkampN, EridaniS, Powles R, LawlerSD, GroffenJ, Foulkes JG, Greaves MF, WiedemannLM (1987): A novel abl protein expressed in Philadelphiapositive acute lymphoblastic leukaemia. Nature 3 2 5 6 3 5 4 3 7 , Chang JS, SanthanamR, Trotta R, Neviani P, Eiring AM, Briercheck E, Ronchetti M, Roy DC, CalabrettaB, Caligiuri MA, PerrottiD (2007): High levels of the BCWABL oncoproteinare requiredfor the MAPK-hnRNP-E2dependentsuppressionof CEBPalpha-drivenmyeloid differentiation.Blood I10:994-1003. Chase A, Pickard J, Szydlo R, Coulthard S, Goldman JM, Cross NCP (2000): Non-random involvement of chromosome 13 in patientswith persistentor relapseddisease afterbone-marrow transplantationfor chronic rnyeloid leukemia. Genes Chromosomes Cancer 27:278-284. Chen SJ,Chen Z, Font MP, d’Auriol L, LarsenCJ, Berger R (1989): Structuralalterationsof the BCR and ABL genes in Phl positive acute leukemias with rearrangementsin the BCR gene first intron: furtherevidence implicating Alu sequences in the chromosome translocation.Mucleic Acids Res 17~763 1-7642. Chen KS, Manian P, Koeuth T, Potocki L, Zhao Q, Chinault AC, Lee CC, Lupski JR (1997): Homologous recombination of a flanking repeat gene cluster is a mechanism for a common contiguous gene deletion syndrome. Nat Genet 17:154-163. Chissoe SL, BodenteichA, Wang YF, WangYP, BurianD, Clifton SW, CrabtreeJ, FreemanA, Iyer K, JianL, Ma Y, McLauryHJ,PanHQ, SarhanOH, TothS, WangZ, ZhangG, HeisterkampN, Groffen J, Roe BA (1995): Sequence and analysis of the human ABL gene, the BCR gene, and regions involved in the Philadelphiachromosomaltranslocation.Genomics 27:67-82. Clark SS, McLaughlin J, Champlin R, Witte ON (1987): Unique forms of the abl tyrosine kinase distinguish Ph’-positive CML from Ph’-positive ALL. Science 235%-88. Collins SJ,KubonishiI,Miyoshi 1, GroudineMT ( 1 984): Alteredtranscriptionof the c-abl oncogene in K-562 and other chronic myelogenous leukemia cells. Science 225:72-74. Copland M, Hamilton A, Elrick LJ, Baird JW. Allan EK, JordanidesN, Barow M, MountfordJC, Holyoake TL (2006): Dasatinib (BMS-354825) targets an earlier progenitor population than imatinibin primaryCML but does not eliminate the quiescent fraction. Blood 107:4532-4539. CortesJE, TalpazM, Giles F, O’BrienS, Rios MB, Shan J, Garcia-ManeroG, Fader1S, ThomasDA, Wierda W, Ferrajoli A, Jeha S, KantarjianHM (2003): Prognostic significance of cytogenetic clonal evolution in patients with chronic myelogenous leukemia on imatinibmesylate therapy. Blood I01:3794-3800. Daley GQ,Van EttenRA, BaltimoreD (1 990): Inductionof chronicmyelogenous leukemiain mice by the P2 IObcr/ablgene of the Philadelphiachromosome.Science 247:824-830. DeiningerM W ,GoldmanJM, Melo JV (2000): The molecular biology of chronic myeloid leukemia. Blood 96:3343-3356. DeiningerM, BuchdungerE, DrukerBJ (2005): Thedevelopmentof imatinibas a therapeuticagentfor chronic myeloid leukemia. Blood 105:2640-2653.

REFERENCES

199

DeiningerMW,CortesJ, PaquetteR, ParkB, HochhausA, BaccaraniM, Stone R, FischerT, Kantarjian H, NiederwieserD, Gambacorti-PasseriniC, So C, GathmannI, GoldmanJM,SmithD, DrukerBJ, Guilhot F (2007): The prognosis for patients with chronic myeloid leukemia who have clonal cytogenetic abnormalitiesin Philadelphiachromosome-negativecells. Cancer 1 10:1509- 151 9. de Klein A, Geurtsvan Kessel A, Grosveld G, BartramCR, HagemeijerA, Bootsma D, SpurrNK, HeisterkampN, Groffen J, Stephenson JR (1982): A cellular oncogene is translocated to the Philadelphiachromosome in chronic myelocytic leukemia. Nature 3W765-767. de Klein A, van Agthoven T, Groffen C, HeisterkampN, Groffen J, Grosveld G ( 1 986): Molecular analysis of both translocationproductsof a Philadelphia-positiveCML patient.Nucleic Acids Res 14:7071-7082. de la FuenteJ, Merx K, SteerEl, MullerM, Szydlo RM,Maywald0,BergerU, HehlmannR, Goldman JM, Cross NCP, Melo JV, Hochhaus A (2001):ABL-BCR expression does not correlate with deletions on the derivative chromosome 9 or survival in chronic rnyeloid leukemia. Blood 98:2879-2880. DiekmannD, Brill S, GarrettMD, Totty N, Hsuan J, Monfries C, Hall C, Lim L, Hall A (1991): Bcr encodes a GTPase-activatingprotein for p2lrac. Nature 35 I :400-402. DrukerBJ, TamuraS, BuchdungerE, Ohno S, Segal GM, Fanning S, ZimmermannJ, Lydon NB (1 996): Effects of a selective inhibitorof the Abl tyrosinekinase on the growthof Bcr-Abl positive cells. Nat Med 2561-566. DrukerBJ, TalpazM,RestaDJ, Peng B, BuchdungerE, FordJM,LydonNB, KantarjianH, Capdeville R, Ohno-JonesS, SawyersCL (2001): Efficacy and safety of a specific inhibitorof the BCR-ABL tyrosine kinase in chronic myeloid leukemia. N Engl J Med 344:103 1-1037. DrukerBJ, GuilhotF, O’BrienSG, GathmannI, KantarjianH, GattermannN, Deininger MW,Silver RT, Goldman JM, Stone RM, CervantesF, Hochhaus A, Powell BL, Gabrilove JL, Rousselot P, ReiffersJ, Comelissen JJ,HughesT, Agis H, FischerT, VerhoefG, ShepherdJ, Saglio G, Gratwohl A, Nielsen JL,RadichJP,SimonssonB, TaylorK, BaccaraniM, So C, LetvakL, LarsonRA (2006): Five-year follow-up of patients receiving imatinibfor chronic myeloid leukemia. N Engl J Med 355:2408-24 17. ElefantyAG, Cory S (1992): Hematologic disease induced in BALB/c mice by a bcr-ablretrovirusis influencedby the infection conditions. Mol Cell Biol 12:1755-1763. Elefanty AG. HariharanIK, Cory S (1990): bcr-abl, the hallmarkof chronic myeloid leukaemia in man, induces multiple haemopoietic neoplasms in mice. EMBO J 9: 1069-1078. El-ZimaityMM, KantarjianH, TalpazM, O’BrienS, Giles F, Garcia-ManeroG, VerstovsekS, Thomas D, FerrajoliA, Hayes K, Nebiyou Bekele B, Zhou X, Rios MB, Glassman AB,CortesJE (2004): Resultsof imatinibmesylate therapyin chronicmyelogenous leukaemiawith variantPhiladelphia chromosome. Bu J Haematol 125: t87-195. FabariusA, HaferlachC, MullerMC, ErbenP, LahayeT, Giehl M, Frank0,SeifarthW, HehlmannR, Hochhaus A (2007): Dynamics of cytogenetic aberrationsin Philadelphiachromosomepositive and negative hematopoiesisduringdasatinibtherapyof chronicmyeloid leukaemia patientsafter imatinib failure. Haematologica 92:834-837. Feinstein E, Marcelle C, Rosner A, CanaaniE, Gale RP, Dreazen0, Smith SD, Croce CM (1987): A new fused transcriptin Philadelphiachromosomepositive acute lymphoblasticleukaemia.Nature 330386-388. Fialkow PJ, Martin PI, Najfeld V, Penfold GK, Jacobson EU,Hansen JA (1981): Evidence for a multistep pathogenesisof chronic myeiogenous leukemia. Btood 58: 158-1 63. FioretosT, StrombeckB, SandbergT, JohanssonB, BillstromR, Borg A, Nilsson PG, Van Den Berghe H, HagemeijerA, Mitelman F, Hoglund M ( 1999): lsochromosome 17q in blast crisis of chronic myeloid leukemia and in other hematologic malignanciesis the result of clusteredbreakpointsin 17pl1 and is not associated with coding TP53 mutations.Blood 94:225-232.

200

CHRONIC MYELOID LEUKEMIA

Fisher AM, Strike P, Scott C, Moorman AV (2005): Breakpointsof variant9;22 translocationsin chronic myeloid leukemia locate preferentiallyin the CG-richest regions of the genome. Genes Chromosomes Cancer 43:383-389. Fitzgerald PH, Moms CM (199 I): Complex chromosomal translocations in the Philadelphia chromosome leukemias. Serial translocationsor a concerted genomic rearrangement?Cancer Genet Cytogenet 57:143-151. Fujino T, Suzuki A, It0 Y, Ohyashiki K, Hatano Y, Miura 1, Nakamura T (2002): Singletranslocationanddouble-chimerictranscripts:detectionof NUP98-HOXA9 in myeloid leukemias with HOXAll or HOXAl3 breaks of the chromosomal translocation t(7;l l)(p15;p15). Blood 99: 1428- 1433. Gale RP, Canaani E (1 984): An altered abl RNA transcriptin chronic myelogenous leukemia. Proc Natl Acad Sci USA 81:5648-5652. Gishizky ML. Johnson White J. Witte ON (1993): Efficient transplantation of BCR-ABLinduced chronic rnyelogenous leukemia-like syndrome in mice. Proc Natl Acad Sci USA 90:3755-3759. GoldmanJM(2007): How 1 treatchronicmyeloid leukemiain the imatinibera.Blood 1 10:2828-2837. GombartAF, HofmannWK, Kawano S, TakeuchiS, KrugU, Kwok SH, LarsenRJ, Asou H, Miller CW,Hoelzer D, Koeffler HP (2002): Mutations in the gene encoding the transcriptionfactor CCAATlenhancer binding protein alpha in myelodysplastic syndromes and acute myeloid leukemias. Blood 99: 1332-1 340. GroffenJ, StephensonJR, HeisterkampN, de Klein A, BartramCR, GrosveldG ( 1984): Philadelphia chromosomalbreakpointsare clustered within a limited region, bcr, on chromosome 22. Cell 3693-99. Grosveld G, VerwoerdT, van Agthoven T, de Klein A, RamachandranKL, HeisterkampN, Stam K, GroffenJ (1 986): Thechronicmyelocytic cell line K562 containsa breakpointin hcr andproduces a chimeric bcrlc-abl transcript.Mol Cell Biol6:6074 16. Gunsilius E, Duba HC, Petzer AL, KahlerCM, GriinewaldK.StockhammerG, Gab1C, DirnhoferS, Clausen J. Gastl G (2000): Evidence from a leukaemia model for maintenance of vascular endotheliumby bone-marrow-derivedendothelial cells. Lancet 355:1688-169 I . Hikansson P, Nilsson B, Anderson A, Lassen C, GullbergU, FioretosT (2008): Gene expression analysis of BCWABLI -dependenttranscriptionalresponsereveals enrichmentfor genes involved in negative feedback regulation. Genes Chromosomes Cancer 47:267-275. HashimotoT, OhtakiM, KamadaN, YamamotoH, MunakaM (1 990): Applicationof log-linearmodel in inference on karyotypicevolution in chronic myelocytic leukemia. Environ Health Perspecf 87:135-1 41. HehlmannR, Hochhaus A, BaccaraniM (2007): Chronicmyeloid leukaemia.Lancet 370:342-350. HeisterkampN, StephensonJR, Groffen J, Hansen PF, de Klein A, BartramCR, GrosveldG (1983): Localization of the c-abl oncogene adjacentto a translocationbreakpointin chronic myelocytic leukemia. Nature 306:239-242. HeisterkampN, Stam K, Groffen3, de Klein A, Grosveld G ( I 985): Structuralorganizationof the bcr gene and its role in the Ph' translocation.Nature 315:758-761. HeisterkampN, JensterG, Kioussis D, PattengalePK, GroffenJ ( 1991): Human bcr-abl gene has a lethal effect on embryogenesis. Transgenic Res 1:45-53. HermansA, HeisterkampN, von LindernM, van Baal S, MeijerD, van der Plas D, WiedemannLM. Groffen J, Bootsma D, Grosveld G (1987): Unique fusion of bcr and c-abl genes in Philadelphia chromosomepositive acute lymphoblasticleukemia. Cell 51:33-40. Hernandez-BoludaJC,CervantesF, ColomerD, Vela MC, Costa D, Paz MF, EstellerM, MontserratE (2003): Genomic p16 abnormalitiesin the progression of chronic myeloid leukemia into blast crisis: a sequential study in 42 patients. Exp Hematol3 1 :204-2 10.

REFERENCES

201

HondaH, OdaH, Suzuki T, TakahashiT, WitteON, Ozawa K, IshikawaT, Yazaki Y, HiraiH (1998): Developmentof acutelymphoblasticleukemiaand myeloproliferative disorderin transgenicmice expressing p21 Obcrlabl: a novel transgenicmodel for human Ph'-positive leukemias. Blood 91 :2067-2075. Hosoya N, SanadaM, NannyaY,NakazakiK,WangL, HangaishiA, KurokawaM,ChibaS, OgawaS (2006): Genomewidescreeningof DNA copy numberchangesin chronicmyelogenous leukaemia with the use of high-resolutionarray-basedcomparativegenomic hybridization.Genes Chromosomes Cancer 45A82-494. HuettnerCS, Zhang P, Van Etten RA, Tenen DG (2000): Reversibilityof acute B-cell leukaemia inducedby BCR-ABLI. Nut Genet 2457-60. HuettnerCS, KoschmiederS, Iwasaki H, RadomskaHS,Akashi K, Tenen DG (2003): Inducible expressionof BCWABL using human CD34 regulatoryelements results in a megakaryocytic myeloproliferativesyndrome.Blood 1 02:3363-3370. Huntly BJ, Reid AG, Bench AJ, CampbellLJ, Telford N, ShepherdP, Szer J, PrinceHM,TurnerP, GraceC, Nacheva EP, GreenAR (2001): Deletions of the derivativechromosome9 occurat the timeof the Philadelphiatranslocationandprovidea powerfulandindependentprognosticindicator in chronicmyeloid leukemia.Blood 98: 1732-1738. HuntlyBJ, GuilhotF, Reid AG, Vassiliou G, HennigE, FrankeC, Byme J,BrizardA, NiederwieserD, Freeman-EdwardJ, CuthbertG, Bown N, Clark RE. Nacheva EP, Green AR, DeiningerMW (2003):Imatinibimprovesbut may notfully reversethe poorprognosisof patientswith CMLwith derivativechromosome9 deletions. Blood 1022205-221 2. IchimaruM, IshimaruT, BelskyJL ( I 978): Incidenceof leukemiain atomicbombsurvivorsbelonging to a fixed cohortin HiroshimaandNagasaki,1950-7 1. Radiationdose. yearsafterexposure,age at exposure,and type of leukemia.J Radiat Res 19:262-282. lshiharaT, MinamihisamatsuM (1 988): The Philadelphiachromosome.Considerationsbased on studiesof variantPh translocations.Cancer Genet Cytogenet 3215-92. G, VerstovsekS, ShanJ, Rios MB, JabbourE, KantarjianHM,AbruzzoLV, O'BrienS, Garcia-Manero CortesJ (2007): Chromosomalabnormalitiesin Philadelphiachromosomenegative metaphases appearingduringimatinibmesylate therapyin patientswith newly diagnosedchronicmyeloid leukemiain chronicphase. Blood 1102991-2995. JamiesonCH, Ailles LE, Dylla SJ, MuijtjensM, Jones C, ZehnderJL, Gotlib J, Li K, Manz MG, KeatingA, SawyersCL, WeissmanIL (2004): Granulocyte-macrophage progenitorsas candidate leukemic stem cells in blast-crisisCML. N Engl J Med 35 I :657-667. Jeffs AR, Benjes SM, Smith TL, Sowerby SJ, Morris CM (1998): The BCR gene recombines preferentiallywith Alu elements in complex BCR-ABL translocationsof chronic myeloid leukaemia.Hum Mol Genet 7:767-776. Jeffs AR, Wells E, MorrisCM (2001): Nonrandomdistributionof interspersedrepeatelementsin the BCR andABLl genes and its relationto breakpointclusterregions.Genes Chromosomes Cancer 3 2 144- 154. JenningsBA, Mills KI(1 998): c-myc locus amplificationand the acquisitionof trisomy 8 in the evolutionof chronicmyeloid leukaemia.Leuk Res 225399-903. Jiang XY, Trujilio JM, Liang JC (1990): Chromosomalbreakpointswithin the first intron of the ABL gene are nonrandom in patients with chronic myelogenous leukemia. Blood 76597-601. JiangX, SmithC, Eaves A, Eaves C (2007): The challengesof targetingchronicmyeloid leukemia stem cells. Clin Lymphoma Myeloma Suppl2:S71-80. JohanssonB, FioretosT, BillstromR, MitelmanF (1 996): Aberrantcytogeneticevolutionpatternof Philadelphia-positivechronic myeloid leukemia treated with interferon-alpha.Leukemia. 10:1 1 3 4 1 138.

202

CHRONIC MYELOID LEUKEMIA

JohanssonB, FioretosT, MitelmanF (2002): Cytogeneticandmoleculargenetic evolution of chronic myeloid leukemia. Acta Haematol 107:76-94. JcjrgensenHG, Holyoake TL (2007): Characterizationof cancer stem cells in chronic myeloid leukaemia. Biochem SOC Trans 2007:35:1347- 1351. KantarjianH, Giles F, WunderleL, Bhalla K, O'Brien S, WassmannB, TanakaC, Manley P, Rae P, Mietlowski W, Bochinski K, HochhausA, GriffinJD, Hoelzer D, AlbitarM, Dugan M, CortesJ, Alland L, OttmannOG (2006): Nilotinib in imatinib-resistantCML and Philadelphiachromosome-positive ALL. N Engl J Med 3542542-2551. KarasawaM, OkamotoK, MaeharaT, TsukamotoN, MoritaK, NaruseT, OmineM ( I 996): Detection of c-myc oncogene amplificationin a CMLblasticphase patientwith doubleminutechromosomes. Lmk Res 20%-9 I . KanmanK, SallerforsB, Lenhoff S, FioretosT, JohanssonB (2007): Cytogeneticevolution patternsin CML post-SCT. Bone Marrow Transplant 39:165-171. Kelliher MA, McLaughlinJ, Witte ON, Rosenberg N (1990): Inductionof a chronic myelogenous leukemia-like syndrome in mice with v-abl and BCWABL. Proc Natl Acad Sci USA 87:6649-6653. Kolomietz E, MarranoP, Yee K, Thai B, Braude1, Kolomietz A, Chun K, Minkin S. Kamel-ReidS, Minden M, Squire JA (2003): QuantitativePCR identifies a minimal deleted region of 120 kb extending from the PhiladelphiachromosomeABL translocationbreakpointin chronic myeloid leukemia with poor outcome. LRukemia 17:1313-1323. KonopkaJB, WatanabeSM, Witte ON (1984): An alterationof the human c-abl protein in K562 leukemia cells unmask associated tyrosine kinase activity. Cell 37: 1035-1 042. Koschmieder S, Gottgens B, Zhang P, Iwasaki-AraiJ, Akashi K,Kutok JL, DayaramT, Geary K, Green AR, Tenen DG,HuettnerCS (2005):Induciblechronic phase of myeloid leukemia with expansion of hematopoieticstem cells in a transgenicmodel of BCR-ABL leukemogenesis.Blood 105:324-334. KovitzC, KantarjianH,Garcia-ManeroG, AbruzzoLV. CortesJ (2006): Myelodysplasticsyndromes and acute leukemia developing after imatinib mesylate therapy for chronic myeloid leukemia. Blood 108:2811-2813. KozubekS, LukasovaE, MareckovaA, SkalnikovaM, KozubekM, BartovaE, KrohaV. Krahulcova E, Slotova J (1999): The topological organizationof chromosomes9 and 22 in cell nuclei has a determinativerole in the induction of t(9,22) translocationsand in the pathogenesis of t(9,22) leukemias. Chromosoma 108:426435. Kreil S , PfinmannM, HaferlachC, WaghornK, Chase A, HehlmannR, Reiter A, HochhausA, Cross NCP (2007): Heterogeneousprognostic impact of derivativechromosome9 deletions in chronic myelogenous leukemia. Blood 110:1283-1290. Kurzrock R, Shtalrid M, Romero P, Kloetzer WS, Talpaz M, Trujillo JM, Blick M, Beran M, GuttermanJU (1987): A novel c-abl proteinproductin Philadelphia-positiveacute lymphoblastic leukaemia. Nature 325:63 1-635. Lee DS, Lee YS, Yun YS, Kim YR, Jeong SS, Lee YK, She CJ, Yoon SS, Shin HR, Kim Y, Cho HI (2003): A study on the incidence of ABL gene deletion on derivativechromosome9 in chronic myelogenous leukemia by interphasefluorescence in situ hybridizationand its association with disease progression. Genes Chromosomes Cancer 37:29 1-299. Li S, IlariaRL Jr,Million RP, Daley GQ,Van EttenRA (1999): The P190, P210, andP230 formsof the BCWABL oncogene inducea similarchronic myeloid leukemia-like syndromein mice but have different lymphoid leukemogenic activity. J Exp Med 189:1399- I4 12. Lombard0W,Lee FY,Chen P, Norris D, BarrishJC, Behnia K, CastanedaS, CorneliusLA, Das J, Doweyko AM, FairchildC. Hunt JT, lnigo I, JohnstonK, KamathA, Kan D, Klei H, MaratheP, Pang S, Peterson R, Pitt S, Schieven GL, SchmidtRJ, TokarskiJ, Wen ML, Wityak J, Borzilleri

REFERENCES

203

RM (2004): Discovery of N-(2-chloro-6-methyl-phenyl)-2-(6-(4-(2-hy~oxyethy~)-piperazin-lyl)-2-methylpyrimidin-4-ylamino)thi~ole-5-carboxamide (BMS-354825), a dual Src/Abl lcinase inhibitor with potent antitumor activity in preclinical assays. J Med Chem 47:6658-6661. Lug0 TG, PendergastAM, MullerAJ, Witte ON (1 990): Tyrosinekinase activity and transformation potency of bcr-abl oncogene products.Science 247: 1079-1082. Maloisel F,Laplace A, Uettwiller F, LioureB, OberlingF (1997): Unusualcytogenetic evolution in CML treated with interferon-alpha.Leukemia 1 1 :893-894. Maru Y, Witte ON (1 991): The BCR gene encodes a novel serine/threoninekinase activity within a single exon. Cell 67:459-468. McKeithanTW, WarshawskyL, Espinosa R 3rd, LeBeau MM (1992): Molecular cloning of the breakpointsof a complex Philadelphiachromosome translocation:identificationof a repeated region on chromosome 17. Proc Natl Acad Sci USA 89:49234927. McWhirter JR, Wang JY ( 199 1): Activation of tyrosinase kinase and microfilament-binding functionsof c-abl by bcr sequences in bcr/abl fusion proteins. Mol Cell Biol 11:1553-1565. MedinaJ, KantajianH, TalpazM, O’Brien S, Garcia-ManeroG, Giles F, Rios MB, HayesK, CortesJ (2003): Chromosomalabnormalitiesin Philadelphiachromosome-negativemetaphasesappearing during imatinib mesylate therapy in patients with Philadelphia chromosome-positive chronic myelogenous leukemia in chronic phase. Cancer 98: 1905-1 91 1. Melo JV, Deininger MW (2004):Biology of chronic myelogenous leukemia-signaling pathwaysof initiationand transformation.Hematol Oncol Clin North Am 18545-568. Melo JV, Barnes DJ (2007): Chronicmyeloid leukaemiaas a model of disease evolution in human cancer. Nat Rev Cancer 7:44 1-453. Melo JV, Gordon DE, Cross NCP, Goldman JM (1993): The ABL-BCR fusion gene is expressed in chronic myeloid leukemia. Blood 8 I :158-1 65. Melo JV, Hochhaus A, Yan XH, Goldman JTi4 (1996): Lack of correlation between ABL-BCR expression and response to interferon-alphain chronic myeloid leukaemia. Br J Haematol 92:684-686. Mes-MassonAM, McLaughlinJ, Daley GQ, PaskindM, WitteON ( 1986):OverlappingcDNA clones define the complete coding region for the €210 c-abl gene product associated with chronic myelogenous leukemiacells containing the Philadelphiachromosome. Proc Natl Acad Sci USA 83 :9768-9772. MiethingC, GrundlerR, Mugler C, BreroS, Hoepfl J, Geigl J, SpeicherMR, Ottmann0,Peschel C, Duyster J (2007): Retroviralinsertionalmutagenesisidentifies RUNX genes involved in chronic myeloid leukemia disease persistence under imatinib treatment. Proc Natl Acad Sci USA 104A594-4599. Y,Nucifora G (2006): Normaland transformingfunctionsof Mikhail FM, Sinha KK, Saunthararajah RUNXI: a perspective. J Cell Physiol207:582-593. Mitelman F, Levan G, Nilsson PG, Brandt L (1976): Non-randomkaryotypicevolution in chronic myeloid leukemia. Znt J Cancer 18:24-30. MitelmanF,JohanssonB, MertensF, editors(2008): MitelmanDatabaseof ChromosomeAberrations in Cancer. Available at http://cgap.nci.nih.gov/Chromosomes/Mitelman. MullighanCG, Miller CB, RadtkeI, Phillips LA, Dalton J, Ma J, White D, HughesTP, Le Beau MM, Pui CH, Relling MV, Shurtleff SA, Downing JR (2008): BCR-ABLI lymphoblastic leukaemiais characterizedby the deletion of Ikaros. Nature 453: 110-1 14. NakamuraT, LargaespadaDA, Lee MP, JohnsonLA, OhyashikiK, ToyamaK, Chen SJ, WillmanCL, Chen IM, Feinberg AP. Jenkins NA, Copeland NG, Shaughnessy JD Jr (1996): Fusion of the nucleoporingene NUP98 to HOAX9 by the chromosometranslocationt(7; I l)(p15;p 15) in human myeloid leukaemia.Nat Genet 12:154-158.

204

CHRONIC MYELOID LEUKEMIA

NakamuraT, YamazakiY, HatanoY,MiuraI (1 999): NUP98 is fused to PMXl homeobox gene in human acute myelogenous leukemia with chromosome translocationt( 1; I l)(q23;p15).Blood 94:74 1-747. Neves H,RamosC, daSilva MG,ParreiraA, ParreiraL ( 1999):Thenucleartopographyof ABL, BCR, PML, and RARalphagenes: evidence for gene proximityin specific phases of the cell cycle and stages of hematopoieticdifferentiation.Blood 93: 1 197-1 207. NotariM, Neviani P,SanthanamR, BlaserBW, ChangJS, GaliettaA, Willis AE, Roy DC, Caligiuri MA, MarcucciG, PerrottiD (2006): A MAPWHNEWKpathwaycontrolsBCWABLoncogenic potentialby regulatingMYC mRNA translation.Blood 107:2507-25 16. Nowell P, HungerfordD (1960): A minute chromosomein human granulocyticleukemia.Science 132:1497. O’BrienSG, GuilhotF, LarsonRA, GathmannI, BaccaraniM, CervantesF, CornelissenJJ,FischerT, Hochhaus A, Hughes T, Lechner K, Nielsen JL, Rousselot P, Reiffers J, Saglio G,ShepherdJ, Simonsson B, Gratwohl A, Goldman JM, KantarjianH, Taylor K, Verhoef G, Bolton AE, Capdeville R, Druker BJ (2003): hatinib compared with interferonand low-dose cytarabine for newly diagnosed chronic-phasechronicmyeloid leukemia.N Engl J Med 348:994-1004. ODwyer ME, Gatter KM, Loriaux M, Druker BJ. Olson SB, Magenis RE, Lawce H, Maum MJ. MaziarzRT, BrazielRM (2003): Demonstrationof Philadelphiachromosomenegativeabnormal clones in patientswith chronicmyelogenousleukemiaduringmajorcytogeneticresponsesinduced by imatinibmesylate. Leukemia 17:481-487. O’Dwyer ME, Mauro MJ, Blasdel C, FarnsworthM, Kurilik G, Hsieh YC, Mori M, Druker BJ (2004): Clonal evolution and lack of cytogeneticresponseare adverseprognosticfactorsfor hematologic relapse of chronic phase CML patients treated with imatinib mesylate. Blood 103:451-455. Offit K, Bums JP, CunninghamI, JhanwarSC, Black P, KernanNA, OReilly RJ, ChagantiRSK (1 990): Cytogeneticanalysisof chimerismandleukemiarelapsein chronicmyelogenousleukemia patientsafterT cell-depletedbone marrowtransplantation. Blood 75: 1346-1355. Pabst T,Mueller BU, Zhang P, RadomskaHS, NarravulaS, SchnittgerS, Behre G, HiddemannW, Tenen DG (200 I): Dominant-negativemutations of CEBPA,encodingCCAAT/enhancerbinding protein-alpha(CEBPalpha),in acute myeloid leukemia. Nut Genet 27:263-270. PabstT,StillnerE, Neuberg D, Nimer S, Willman CL, List AF, Melo JV, Tenen DG, Mueller BU (2006):Mutationsof themyeloid transcriptionfactorCEBPAarenot associatedwith theblastcrisis of chronic myeloid leukaemia.Br J Huemato1 133:400402. PaneF,FrigeriF, SindonaM, LucianoL, FerraraF, ChinoR, Meloni G, SaglioG, SalvatoreF, Rotoli B (1996): Neutrophilic-chronicmyeloid leukemia: a distinctdisease with a specific molecular marker(BCRIABLwith C31A2 junction).Blood 88:241%2414. Paulsson K, JohanssonB (2007): Trisomy 8 as the sole chromosomalaberrationin acute myeloid leukemiaand myelodysplasticsyndromes.Pathol Biol55:37-48. PearWS,MillerJP,Xu L, Pui JC, SofferB, QuackenbushRC, PendergastAM, BronsonR, AsterJC. Scott ML, BaltimoreD (1998): Efficientand rapid inductionof a chronicmyelogenousleukemialike myeloproliferativedisease in mice receiving P210 bcrlabl-transducedbone marrow.Blood 92:3780-3792. Perrotti D, Cesi V, TrottaR, Guerzoni C, Santilli G, Campbell K, lervolino A, Condorelli F, Gambacorti-PasseriniC, CaligiuriMA, CalabrettaB (2002): BCR-ABL suppressesCEBPalpha expression throughinhibitoryaction of hnRNPE2. Nut Genet 30:48-58. A, KantarjianH, TalpazM, O’Brien S, Garcia-ManeroG, VerstovsekS, Rios MB, Quintas-Cardama Hayes K, Glassman A, Bekele BN, Zhou X, Cortes3 (2005): Imatinibmesylate therapy may overcomethepoorprognosticsignificanceof deletionsof derivativechromosome9 in patientswith chronicmyelogenous leukemia. Blood 105:2281-2286.

REFERENCES

205

Quintas-CardamaA, KantarjianH, Cortes J (2007): Flying underthe radar:the new wave of BCRABL inhibitors.Nut Rev Drug Discov 6:834-848. Radich JP (2007): The biology of CML blast brisis. Hematology 2007:384-391. RadichJP,Dai H. Mao M, OehlerV, SchelterJ, DrukerB, SawyersC, ShahN, Stock W, WillmanCL, FriendS, Linsley PS (2006):Gene expressionchangesassociated with progressionandresponsein chronic myeloid leukemia. Proc Natl AcadSci USA 103:2794-2799. RaskindWH, FerrarisAM, Najfeld V, JacobsonRJ. MoohrJW, Fialkow PJ (1993):Furtherevidence for the existence of a clonal Ph-negative stage in some cases of Ph-positive chronic myelocytic leukemia. Leukemia 7: 1163-1 167. Reid AG, Nacheva EP (2005): Genesis of derivative chromosome 9 deletions in chronic myeloid leukaemia. Genes Chromosomes Cancer 43:223-224. Reid AG, Huntly BJ, Grace C, Green AR, Nacheva EP (2003): Survival implications of molecular heterogeneity in variant Philadelphia-positive chronic myeloid leukaemia. Br J Haematol I 2 I :419427. Ren R (2005):Mechanismsof BCR-ABLin the pathogenesisof chronicmyelogenous leukaemia.Nut Rev Cancer 5:172-183. Roche-LestienneC, Deluche L, Corm S, TigaudI, JohaS, PhilippeN, Geffroy S, LaiJL, Nicolini FE, PreudhommeC (2008):RUNX 1 DNA-bindingmutationsandRUNXl -PRDM16crypticfusions in BCR-ABL leukemias are frequentlyassociated with secondarytrisomy 2 1 and may contribute to clonal evolution and imatinibresistance.Blood I 1 I :3735-374 I. Roix JJ,McQueen PG, Munson PJ, ParadaLA, Misteli T (2003): Spatialproximityof translocationprone gene loci in human lymphomas.Nai Genet 34:287-291. Ross ME, Zhou X, Song G , ShurtleffSA, GirtmanK, Williams WK, Liu HC, Mahfouz R, Raimondi SC. Lenny N, Patel A, Downing JR (2003): Classification of pediatric acute lymphoblastic leukemia by gene expression profiling.Blood I02:2951-2959. Rowley JD (1973): A new consistent chromosomalabnormalityin chronic myelogenous leukemia identified by quinacrinefluorescence and Giemsa staining. Nature %3:290-293. Roy L.GuilhotJ. KrahnkeT,Guerci-BreslerA, DrukerBJ, LarsonRA, O’BrienS, So C, MassiminiG, GuilhotF(2006): Survivaladvantagefrom imatinibcomparedto the combinationinterferon-aplus cytarabine in chronic phase CML. historical comparison between two phase HI trials. Blood 108:1478-1484. Saglio G, Storlazzi CT,Giugliano E, Surace C, Anelli L, Rege-CambrinG, Zagaria A, Jimenez Velasco A, HeinigerA, ScaravaglioP,TorresGomez A, RomanGomezJ, ArchidiaconoN, Banfi S , Rocchi M (2002): A 76-kb dupliconmaps close to the BCR gene on chromosome22 and the ABL gene on chromosome 9: possible involvement in the genesis of the Philadelphiachromosome translocation.Proc Natl Acad Sci USA 99:9882-9887. Savona M,Talpaz M (2008): Getting to the stem of chronic myeloid leukaemia. Nut Rev Cancer 8: 341-350. SawyersCL, CallahanW, Witte ON (1992):Dominantnegative MYC blocks transformationby ABL oncogenes. Cell 70901-910. Scheurlen WG, Schwabe GC, Seranski P, Joos S, Harbott J, Metzke S, Dohner H, Poustka A, WilgenbusK, Haas OA ( I 999): Mappingof the breakpointson the shortarm of chromosome17 in neoplasms with an i( 17q). Genes Chromosomes Cancer 25:230-240. Schoch C, HaferlachT, Kern W, SchnittgerS, BergerU, HehlmannR, HiddemannW, Hochhaus A (2003):Occurrenceof additionalchromosomeaberrationsin chronicmyeloid leukaemiapatients treatedwith imatinib mesylate. Leukemia 17:461463. Serra A, GottardiE, Della Ragione F, Saglio G, Iolascon A (1995): Involvement of the cyclindependentkinase-4 inhibitor(CDKN2)gene in the pathogenesisof lymphoidblastcrisis of chronic myelogenous leukaemia. Br J Haematol91:625-629.

+

206

CHRONIC MYELOID LEUKEMIA

Sessarego M, FrassoniF. DeffemariR, Bacigalupo A. FugazzaG, MareniC. Bruzwne R, DejanaA, Ajmar F (199 I): Karyotype evolution of Ph positive chronic myelogenous leukemia patients relapsedin advancedphases of the disease after allogeneic bone marrowtransplantation.Cancer Genet Cytogenet 57:69-78. Shah NK, WagnerI, Santos G, GriffinCA (1 992): Karyotypeat relapse following allogeneic bone marrowtransplantationfor chronicmyelogenous leukemia.Cancer Genet Cytogenet 61: 183-1 92. ShahNP, TranC, Lee FY, ChenP, Noms D, SawyersCL (2004): Overridingimatinibresistancewith a novel ABL kinase inhibitor.Science 305:399-401. ShtivelmanE, Lifshitz B, Gale RP, CanaaniE ( 1985): Fused transcriptof abl and bcrgenes in chronic myelogenous leukaemia. Nature 3 15:550-554. Sill H, Goldman JM, Cross NCP (1995): Homozygous deletions of the p16 tumor-suppressorgene are associatedwith lymphoid transformationof chronic myeloid leukemia. Blood 85:2013-201 6. SinclairPB, Nacheva EP, LevershaM, TelfordN, ChangJ, Reid A. Bench A. ChampionK. HuntlyB, GreenAR (2000): Largedeletions at the t(9;22) breakpointare common and may identify a poorprognosis subgroupof patients with chronic myeloid leukemia. Blood 95738-743. Sokal JE,Gomez GA, BaccaraniM, TuraS, ClarksonBD, CervantesF, RozmanC, CarbonellF, Anger B, Heimpel H, Nissen NI,RobertsonJE (1988): Prognostic significance of additionalcytogenetic abnormalitiesat diagnosis of Philadelphiachromosome-positive chronic granulocyticleukemia. Blood 72:294-298. Sowerby SJ, Kennedy MA, Fitzgerald PH, MorrisCM (1993): DNA sequence analysis of the major breakpointcluster region of the BCR gene rearrangedin Philadelphia-positivehumanleukemias. Oncogene 8: 1679-1 683. Stam K, HeisterkampN, Grosveld G, de Klein A, Verma RS, ColemanM, Dosik H, GroffenJ ( 1985): Evidence of a new bcr/c-abl mRNA in patients with chronic myelocytic leukemia and the Philadelphiachromosome. N Engl J Med 3 13:1429- 1433. Talpaz M, Shah NP, KantajianH, Donato N, Nicoll J, PaquetteR, CortesJ, O'Brien S, Nicaise C, Bleickardt E, Blackwood-ChirchirMA, lyer V, Chen IT, Huang F, Decillis AP, Sawyers CL (2006): Dasatinib in imatinib-resistantPhiladelphiachromosome-positive leukemias. N Engl J Med 354:253 1-2541. Terre C, Eclache V, Rousselot P, Imberi M, Chamn C, Gervais C, Mozziconacci MJ, Maarek0, Mossafa H, Auger N, Dastugue N, Talmant P, Van den Akker J, LeonardC, NGuyen Khac F, MugneretF, Viguie F, Lafage-PochitaloffM, Bastie JN, Roux GL, Nicolini F, Maloisel F, Vey N, LaurentG , RecherC, Vigier M, YacoubenY, GiraudierS, VernantJP,Salles B, Roussi J, Castaigne S, Leymarie V, FlandrinG, Lessard M (2004): Report of 34 patients with clonal chromosomal abnormalitiesin Philadelphia-negativecells during imatinib treatmentof Philadelphia-positive chronic myeloid leukemia. Leukemiu 18:1340- 1346. VardimanJW, BrunningRD, Hanis NL (2001): WHO histological classification of chronicmyeloproliferative diseases. In: Jaffe ES, Hams NL. Stein H, VardimanJW, editors. World Health Organizution Clussification of Tumors: Tumors of the Haematopoietic und Lymphoid Tissues. Lyon, France: InternationalAgency for Research on Cancer(IARC) Press, pp 20-26. Verstovsek S, Lin H, KantarjianH, Saglio G, De Micheli D, Pane F, Garcia-ManeroG, lntrieriM, Rotoli B, Salvatore F, Guo JQ, Talpaz M, Specchia G, Pizzolo G, Liberati AM, Cortes J. QuackenbushRC, ArlinghausRB (2002): Neutrophilic-chronicmyeloid leukemia: low levels of p230 BCWABL mRNA and undetectable BCWABL protein may predict an indolent course. Cancer 94:2416-2425. VirtanevaK, Wright FA, TannerSM, Yuan B, Lemon WJ, Caligiuri MA, Bloomfield CD, de la Chapelle A, KraheR (200 I ): Expression profiling reveals fundamentalbiological differences in acute myeloid leukemiawith isolated trisomy 8 and normalcytogenetics. Proc NatlAcadSci USA 98: 1124-1 129.

REFERENCES

207

VonckenJW, KaartinenV, PattengalePK, GermeraadWT, GroffenJ, HeisterkampN (1995): BCW ABL P210 and PI90 cause distinct leukemiain transgenicmice. Blood 86:46034611. Walker LC, Ganesan TS, Dhut S, Gibbons B, Lister TA, RothbardJ, Young BD (1987): Novel chimaeric protein expressed in Philadelphiapositive acute I ymphoblastic leukaemia.Nature 329:851-853. Wang JY (2000): Regulationof cell deathby the Abl tyrosine kinase. Oncogene 19:5643-5650. WeisbergE, Manley PW, BreitensteinW, BriiggenJ, Cowan-JacobSW, Ray A, HuntlyB, FabbroD, FendrichG, Hall-MeyersE,Kung AL, MestanJ, Daley GQ, CallahanL, Catley L, CavazzaC, of AMNlO7,a Azam M, NeubergD, WrightRD. GillilandDG, GriffinJD (2005):Characterization selective inhibitorof native and mutantBcr-Abl. CancerCell 7:129-141. Yehuda0,AbeliovichD, Ben-NeriahS,SverdlinI, CohenR, VaradiG,Orr R, AshkenaziYJ, Heyd J, Lugassy G, Ben Yehuda D (1999): Clinical implicationsof fluorescence in situ hybridization analysisin I3chronicmyeloid leukemiacases: Ph-negativeand variantPh-positive.CancerGenet Cytogenet I14:100-107. Yoong Y, VanDeWalkerTJ, Carlson RO, Dewald GW, Tefferi A (2005): Clinical correlates of submicroscopic deletions involving the ABL-BCR translocationregion in chronic myeloid leukemia. Eur J Haematol74:124-127. ZhangX, Ren R (1998): Bcr-Ablefficiently inducesa myeloproliferativedisease and productionof excess interleukin-3and granulocyte-macrophage colony-stimulatingfactor in mice: a novel model for chronicmyelogenousleukemia.Blood 92:3829-3840. ZhangSJ,Ma LY, HuangQH, Li G, Gu BW, Gao XD, Shi JY, WangYY,GaoL, Cai X, Ren RB, ZhuJ, ChenZ, Chen SJ (2008):Gain-of-functionmutationof GATA-2in acutemyeloidtransformation of chronicmyeloid leukemia.ProcNatl Acad Sci USA 105:2076-208 1.

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CHAPTER8

Chronic Myeloproliferative Neoplasms PETER VANDENBERGHE. LUCIENNE MICHAUX,and ANNE HAGEMEIJER

Myeloproliferativedisorders (MPD) are clonal hematological malignancies derived from a common stem cell and characterizedby proliferationin the bone marrowof one or more of the myeloid (ie., granulocytic, erythroid,and megakaryocytic)lineages (Fialkow et al., 198I ;Raskindet al., 1985). Importantly,the proliferativeprocess occurs with relativelynormalandeffectivematuration.Thisresultsin increasednumbersof mature erythrocytes,granulocytes,and plateletsin the peripheralblood, which distinguishesthis group of diseases from the myelodysplastic syndromes (MDS), the myelodysplastic/ myeloproliferativediseases (MDSNPD),and acutemyeloid leukemia(AML). As became establishedrecently,so-called Class I mutationsare criticalevents in the pathogenesisof MPD (Tefferi and Gilliland, 2007). These are acquiredmutationsor rearrangementsof genes encodingtyrosinekinasesor relatedmoleculesthatconvey a proliferationadvantage on the cells harboringthem. PolycythemiaVera (PV), chronicidiopathicmyelofibrosis(CIMF)(also called primary myelofibrosis or agnogenic myeloid metaplasia (AMM)), essential thrombocythemia (ET), and chronic myeloid leukemia (CML) are the so-called classic MPD. According to the 2001 WHO classification of myeloid neoplasms, the classic MPD belong to the largergroupof chronicmyeloproliferativediseases (CMPD),which also comprisechronic neutrophilicleukemia(CNL),chroniceosinophilicleukemia/hypereosinophilicsyndrome (CEL/HES), and CMPD, unclassifiable.Atypical chronic myeloid leukemia (aCML), chronic myelomonocytic leukemia (CMML), juvenile myelomonocytic leukemia (JMML),and myelodysplastic/myeloproliferativedisease, unclassifiable,were assigned to the “myelodysplastic/myeloproliferative diseases,” a separatecategory of myeloid neoplasms (Vardimanet al., 2002). In the revised 2008 WHO classification, the term CMPD is substitutedby “myeloproliferativeneoplasms”(MPN),which also includesthe mast cell diseases. Conversely, myeloid neoplasms associated with eosinophilia and abnormalitiesof the PDGFRA, PDGFRB, and FGFRl genes are identifiedand treated as a separatecategory from MPN (Tefferi and Vardiman,2008), reflectinga tendency towardgenetic classificationbased on disease-specificmolecularmarkers(Table8.1). As CML is covered separately in Chapter7, the present survey will be devoted to the

Cuncer Cytogeneticx, Third Edition. edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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TABLE 8.1 2008 World Health Organization (WHO) ClassificationScheme for Myeloid Neoplasms (Tefferi and Vardiman, 2008) (1 ) Acute myeloid leukemia (AML) (2) Myelodysplastic syndromes(MDS) (3) Myeloproliferativeneoplasms (MPN) Chronic myelogenous leukemia PolycythemiaV e r a Essential thrombocythemia Primarymyelofibrosis Chronic neutrophilicleukemia Chroniceosinophilic leukemia, not otherwise categorized Hypereosinophilicsyndrome Mast cell disease MPNs, unclassifiable (4) Myeloid neoplasms associated with eosinophilia and abnormalitiesof PDGFRA, PDGFRB, or FGFR 1 Myeloid neoplasms associated with PDGFRA rearrangement Myeloid neoplasms associated with PDGFRBrearrangement Myeloid neoplasms associated with FGFRl rearrangement(8pl1 myeloproliferativesyndrome) (5) Myelodysplastic syndromedmyeloproliferativrneoplasms (MDSMPN) Chronicmyelomonocytic leukemia Juvenile myelomonocytic leukemia Atypical chronic myeloid leukemia MDS/MPN, unclassifiable

remainingBCR-ABL-negativeMPN, includingmast cell disease, and myeloid neoplasms with abnormalitiesof PDGFRA,PDGFRB, and FGFRl. The currentclassificationof MPN remainsbased on the myeloid lineage thatis most prominentlyinvolved as well as on the presenceof bone marrowfibrosistogetherwith a constellationof clinical and other laboratoryfeatures.An increasedred cell mass is the hallmarkof PV, whereasexcessive productionof plateletsis the distinguishinganomalyof ET. The dominatingbone marrowchanges in CIMFare myeloid metaplasiaand reactive fibrosis.Sometimesa clear-cutdistinctioncannotbe madeandtransitionsfromone type to anothercan occur. Common to all is evolution towardbone marrowfibrosiswith extramedullaryhematopoiesisand a tendency to progress to AML.

THE CLASSIC BCR-ABL-NEGATIVEMYELOPROLIFERATIVEDISORDERS: POLYCYTHEMIA VERA, CHRONIC IDIOPATHIC MYELOFIBROSIS,AND ESSENTIAL THROMBOCYTHEMIA Cytogeneticabnormalitiesarereportedin only a minorfractionof caseswith thesedisorders at diagnosis.Most of them are recurrentchangesin myeloid disordersthatarenot specific forany particularmyeloproliferativeneoplasmoreven the myeloproliferativeneoplasmsin general. The percentageof abnormalkaryotypesincreases with disease progressionand reaches90%at thetime of leukemictransformation. It is not entirelyclearto whatextentthis clonal evolutionis an integralpartof the naturalhistoryof these diseases,or whetherit is attributableto long-termexposureto myelosuppressiveagents.

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Althoughkaryotypicabnormalitiesareidentifiedin only a minorityof cases, cytogenetic investigationsremainimportant.First,althoughnonspecific,they can confirmthata clonal diseaseis present,therebyunequivocallyrulingouta reactivemyeloproliferation.Second,it is necessaryto exclude a Philadelphia(Ph) chromosome(Chapter7) before a diagnosisof PV, ET, or CIMFcan be made. Finally,cytogenetics may be needed in the follow-up of patientswith chronicmyeloproliferativedisorders,as leukemicevolutionis oftenassociated with progressiontowardmore complex karyotypes. Recently,fourgroupsalmostsimultaneouslyreportedan activatingmutationof theJAK2 tyrosinekinase gene in nearlyall cases of PV and in abouthalf of ET and CIMFcases. The concernedpoint mutationconsistsof a G-T transversionresultingin a valine to phenylalanine substitutionat position6 17 in the JH2domainof theJAK2cytoplasmictyrosinekinase (JAK2 V617F) (Baxter et al., 2005; James et al., 2005; Kralovics et al., 2005; Levine et al., 2005b). Given thatthe JAK2 V617F mutationis much more prevalentin MPN than arecytogeneticabnormalities,andthatit is not detectableby karyotypicanalysis,molecular demonstrationof this abnormalityis rapidlybecomingthe gold standardfor demonstrating clonality when these diseases are suspected. As a result, the role of cytogenetics in establishingthe diagnosis of a MPD may tend to diminish in the future.But since the presence of karyotypeabnormalitiesat diagnosis has a prognosticallynegative impact (Bench and Pahl,2005), a comprehensivediagnosticapproachincludingcytogeneticswill continueto yield importantinformationthat cannotbe obtainedotherwise.

Polycythemia Vera (PV) Disease Summary PolycythemiaVera is a relatively rare disease (annualincidence 1-2 per 100,000)with a medianage of 60 yearsat diagnosis.Most studiesindicatea slight male predominancewith an M:F ratio of 1-2: I. The hallmarkof PV is excessive and autonomousproductionof red blood cells resultingin absolute erythrocytosis.In about 25% of patients, the disease presents with circulatory disturbancessuch as bleeding or venous or arterial thrombotic episodes. Patients may also complain of headache, dizziness, and visual disturbances. Other typical complaints are aquagenic pruritus, erythromelalgia, and gout. However, the course is often insidious with incidental diagnoses in about 50%of cases. Facial plethora and palpable hepato- and/or splenomegaly are the most common physical findings.If correctlytreated.PV has an excellent prognosis with a median survival time of 10 years and a normal to near-normallife expectancy.At later stages of the disease, the red cell mass will normalizeand decrease with evolution to anemia, and the spleen becomes enlarged.This is usually referredto as the “spentphase” of PVoras postpolycythemicmyelofibrosis(PPMF),at which stagethe disordermay be indistinguishablefromCIMF.Progressionto AMLoccursin a minorityof patients.It is not entirelyclearwhethersuchtransitionis partof the naturalcourseof PVor caused by the genotoxic treatmentreceived by some patients. Fora long time, PV used to be a diagnosisthatstrictlyrequiredthe demonstrationof an increasedredcell mass (A1 criterion)andtheexclusionof a long list of causesof secondary erythrocytosis(A2 criterion).The presenceof one additionalA criterion(splenomegaly, clonalcytogeneticabnormalities,orendogenouserythroidcolonyformationin vitro)or two B criteria(thrombocytosis,neutrophilleukocytosis,typical marrowbiopsy, and low serum EPO) was necessary (Vardimanet al., 2002). In this context, the demonstrationof any chromosomalaberrationwas importantas an unequivocal indication of clonality, thus obviatingan extensive exclusion of conditionscausing secondaryerythrocytosis.

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Cytogenetics The incidenceof cytogeneticabnormalitiesin PV at diagnosisis uncertain, probablyreaching 15-25%. However, this frequency increasessteeply duringlater diseasephasesto perhapsas muchas 6 0 4 0 %amongtreatedpatients,thusgiving an overall estimateof 40% (Bergeret al., 1984;Rege-Cambrinet al., 1987; Swolin et al., 1988;DiezMartinet al., 1991; Mertenset al., 1991; Bacheret al., 2005). Partof this change may be attributableto the type of treatment:Swolin et al. ( 1988)reportedmoreabnormalitiesin PV patientswho had receivedmyelosuppressiveagentsthanin thosewho had been treatedwith phlebotomy.Of the cytogeneticallyabnormalpatients,about half of those experiencing diseaseprogressionhad karyotypicchangesalreadyprecedingthe developmentof myeloid metaplasiaand myelofibrosis. Nearly all cases with terminal evolution toward acute leukemiahave an abnormalbone marrowkaryotype(GroupeFranGaisde CytogCnCtique HCmatologique,1988; Diez-Martinet al., 1991). The five most commonaberrationsare,in decreasingorderof frequency,20q-, +8, +9, alterationsof 9p, gains of Iq, and 13q- (Fig. 8.1). Two-thirdsof the cytogenetically abnormalcases display at least one of these aberrations. 20q-: A deletion of an F-groupchromosomein PV was firstdescribedby Lawlerand coworkersin 1966, and in 1972, the same groupidentifiedthe aberrantchromosomeas a 20q- (Lawler, 1980). In subsequentstudies,numerousinvestigatorsconfirmedthe associationbetweenthe deletionandthisMPD subgroup(Aatolaetal., 1992).The incidenceofthe 20q- markerin PV has been reportedin variousstudiesto be between25%and 30%of the abnormalcases. As demonstratedby several fluorescence in situ hybridization(FISH) studies,20q- is an interstitialdeletionof variableextentthatis usuallydescribedas del(20) (91 lq12) or del(20)(ql lq13) (Roulstonet al.. 1993; Bench et al., 2000). Detailed FISH analysesusing probesforthe markerD20S I F08 have in some cases also identifieda cryptic del(2Oq) not seen by banding(Nachevaet al., 1995). The shortestcommondeletedregion still containssix genes, and the putativetumorsuppressorgene has not yet been identified (MacGroganet al., 2001). A very raretranslocation,t( 1 1 ;20)(p15;qll), resultingin the NUP98-TOP1 fusion gene has been describedin therapy-relatedAML and in one case of PV (Busson et al., 2004).

del(13q)

t(5;12)(q33;pl3)

n m m

del(20)(qllq12-13)

t(8;13)(pl1 ;q12)

I

E

t(8;22)(pl1 ;ql1)

m

m

FIGURE 8.1 Examples of cytogenetic aberrations seen in myeloproliferations (R-banding with acridine orange). del( 13q) may vary in length: del( 13)(q 13q21) in a case of ET, del(l3)(q 13q22) in a case of CIMF, and del( 13)(q 13q33) in a case of ET; del(20)(q 1 lq12- 13) in a case of CIMF; t(5;12) (q33;p13) in a case of chronic myelomonocytic leukemia and eosinophilia; t(8;13)(pl l;q12) in a patient presenting with AML; and t(8;22)(pl 1;qll) in a patient initially presenting as CML.

THE CLASSIC BCRABL-NEGATIVE MYELOPROLIFERATIVEDISORDERS

213

Trisomy 8: This is a common and nonspecificaberrationin myeloid disorders.It is in PV foundin 20%of abnormalkaryotypes,mostly as the sole changeor associatedwith trisomy 9. It does not have an impacton prognosis. In fact, the combinationof +8 and +9 may persist withoutfurtherclonal evolution and withoutleukemiadevelopmentfor up to two decades. Trisomy 9 and9p Abnormalities: Trisomy9 is seen in 1 6 2 0 %of abnormalkaryotypes, aloneorin associationwith trisomy8. Fluorescencein situ hybridizationresultsindicatethat gain of 9pis the mostfrequentchangein PV (Chenet al., 1998;Najfeldet al., 2002). Genomewide screeningfor loss of heterozygosity(LOH)showedLOHat9p encompassingthe JAK2 gene at9p24 in upto 36%of PV, andalso in some casesof CIMF(Kralovicset al., 2002). This was broughtaboutby mitoticrecombinationleadingto uniparentaldisomy.Theobservation of LOH at 9p was one of the leads thatconvergedon the simultaneousdiscoveryby several groups of the V617F JAK2 mutation(Baxter et al., 2005; James et al., 2005; Kralovics et al., 2005; Levine et al., 2005b). def(l3q):Deletionof the long arm of chromosome13i s observedin approximately10% of abnormalkaryotypesin PV. The deletion is interstitialwith variableboundaries,most frequentlydel( 13)(q13q21), althoughdel( 13)(q13q22)and del( 13)(q12q32)are also reported(Pastoreet a1.,1995; La Starzaet al., 1998). The band 13q14harborsseveralgenes, includingthe RBI gene, the prototypicaltumorsuppressorgene, which is always deleted. The pathogeneticrole of RBI in this context is plausible but not yet firmly established (Sinclairet al., 2001). Gain of I q : Partialtrisomy l q is found in 10-15% of PV with abnormalkaryotypesat diagnosis,butbecomesthe most frequentchange(7690%)in PVevolvingto myelofibrotic phase(PPMF)andat thetime of acutetransformation. Gainof lq maybe the resultof partial interstitialduplication,of an additionalchromosome 1 with deletion in the short arm,or moreoftenof an unbalancedtranslocationof Iq2I -qtermaterialwith an acrocentricorother chromosome.A der(1 ;7)(qlO;pIO)and der(1 ;9)(qlO;p10)have been recurrentlyreported (Swolin et al., 1986;Rege-Cambrinet al., 1991; Chenet al., 1998).The region lq21-32 is always gained. Whetherthereis a link between gain of l q and myelotoxic therapyis still debated. Evolutionof PV to PPMFor AML is usuallyaccompaniedby acquisitionof (additional) chromosomalaberrations,mainly duplication 1q, deletion 5q, deletion 7q, and deletion I7p. Dingli et al. (2006) showed thatthe presenceof unfavorablecytogeneticabnormalities (i.e., clones with aberrationsotherthan2%- and 13q-) was the strongestpredictorof poor survivalin secondarymyelofibrosis.

Essential Thrombocythemia (ET)

Disease Summary Essentialthrombocythemiais characterizedby a sustainedplatelet count of >450 x 109/L and megakaryocytichyperplasiain the bone marrow with a moderate level of fibrosis. Its true incidence is unknown but is estimated at 1 - 2 3 100,00O/year.Survivalis long ( > 10 years) with a limitedrisk of leukemictransformation (1-3%). Earlydisease is often asymptomatic,with more thanhalf of the cases being discovered fortuitously.Arterialand venous thrombo-embolicevents, hemorrhage,and microcirculatory disturbancesare frequentcomplications.Extramedullaryhematopoiesisis common. Modest splenomegalyis presentin approximately50%of the patients. It is importantto distinguishET from secondaryor reactivethrombocytosis,which is much more common.

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CHRONICMYELOPROLIFERATIVE NEOPLASMS

TrueET is a clonal disorderof the myeloid lineage; the T-lymphocytesare polyclonal (Raskindet al., 1985). Extramedullaryhematopoiesisis also clonal, while the fibroblast proliferationin myelofibrosisis reactiveand polyclonal,secondaryto releaseof cytokines by the megakaryocytes.

Cyfogenefics Chromosomeaberrationsarefoundin less than10%of cases at diagnosis (Third International Workshop on Chromosomes in Leukemia, 1981 ; Sessarego et al., 1989). The aberrationsare the same as in other classic MPD, none is specific: del (20q), f8, +9, gain of Iq, del( 13q),anddel(5q).Abnormalitiesof chromosomes7 and 17, 7q-, der(l;7)(qlO;plO), 17p-, and i( 17q) are harbingersof leukemic transformation (Sterkerset al., 1998). Characteristicalterationsof chromosome2 1 have been reported (Zaccariaand Tura, 1978), but the associated clinical syndromedoes not conform to the present-daycriteriafor ET and no subsequentstudieshave confirmedthe findings.Unique balancedtranslocationshavealso been reportedbutthesearesingleeventsandthereis a bias towardreportingsuch cases. Given the low frequency of cytogenetic aberrationsin ET, the role of cytogenetic examinationin the diagnosisof thisdiseaselies mainlyin the exclusionof CMLas the cause of the observedthrombocytosis.In addition,cytogeneticexaminationmay revealdel(5q)or rearrangements involving3q26,abnormalitiesassociatedwiththrombocytosisin the setting of MDS or AML. Chronic Idiopathic Myelofibrosis (CIMF) Disease Summary This condition is also known underthe names myelofibrosiswith myeloid metaplasia(MMM),agnogenicmyeloid metaplasia,myelosclerosis,osteosclerosis, and aleukemicmyelosis. It is characterizedby varyingdegreesof bone marrowfibrosis and extramedullaryhematopoiesis(myeloid metaplasia),with concomitantanemia,poikilocytosis with characteristicteardropforms in the peripheralblood, and circulating immaturegranulocytesanderythroblasts.Men areslightlymoreoftenaffectedthanwomen. The incidence is estimatedat 0.5-1.5/100,000/year. The majorityof patientsare between 50 and 70 years of age. CIMFcarriesa 10-20% risk of subsequentdevelopmentof AML. Cytogenefics Samplingof bone marrowis inefficientin this disease, especially in the fibroticstage(drytap),which explainswhy cytogeneticdatahaveoften been obtainedfrom peripheralblood cultures.A few seriesof CIMFcases havebeen studied,totalingmorethan 500 patients (Dupriez et al., 1996; Reilly et al., 1997; Tefferi et al., 2001; Djordjevic et al., 2007). Chromosomeaberrationsare found in 40-50% of cases, with increasing frequencyas the diseaseprogresses.Recurrentchangessimilarto those in PVarefrequentin CIMF,albeit with differentprevalence.del(13q) and del(20q) arefound in 20-25% of the abnormalkaryotypes.Trisomy8 (15%),trisomy9 (3-lo%), andtrisomy21 (2-5%) arealso fairly frequent.Comparativegenomic hybridization(CGH) studies have shown gains of cytogeneticmaterialin more than 50%of the CIMFpatientsexamined,mostly of or from 9p, 2q, 3p, chromosome4, 12q, and 13q (A1 Assar et al., 2005). Disease progressionis accompaniedby the acquisitionof structuralchanges,for example,gain of 1q (3-19%), del (5q) (3-6%), anomaliesof chromosome7 (5-lo%), del(l7p), and i( 17q) (rare)(Demory et al., 1988; Dupriez et al., 1996; Reilly et al., 1997; Tefferi et al., 2001; Djordjevic et al., 2007; Roche-LestienneandAndrieux,2007). Balancedtranslocationsarerarelyseen in CIMF.Theyoccuras sole abnormalitiesratherthanin complexkaryotypesandfew, if any,

THE CLASSIC BCR-AM-NEGATIVEMYELOPROLIFERATIVE DISORDERS

215

seem to be recurrent.Examplesare t(2;16)(q3l;q24), t(5;13)(q13;q32),t(12;13)(p13;q13), andt( 12;16)(q24;q24)(Djordjevicet al., 2007). Recurrentbreakpointshave been observed at 12q14 leading to overexpressionof HMGA2 (high mobility group protein A2), a transcriptionfactorexpressedin embryonictissue(Andrieuxet al., 2002,2004). A recurrent unbalancedtranslocationmay be t( 1;6)(q21 ;p21)leadingto partialtrisomy lq and deletion 6p (Dingli et al., 2005). In advanceddiseaseandin secondaryMFpost-PVorpost-ET,varioustranslocationswith a 17q22breakpointhave been detectedand shown to involve the NOG gene. Deregulated expressionof the NOG protein may lead to modifiedexpressionof bone morphogenetic proteins(BMPs). BMP deregulationprobablycontributesto the myelofibrosis(Andrieux et al., 2007).

Molecular Changes in Classic MPD A unique,acquiredJAK2 V617F mutationis foundin 95%of PV, 50%of CIMF,and50%of ET patients (Baxter et al., 2005; James et al., 2005; Kralovics et al., 2005; Levine et al., 2005a). A homozygous, biallelic mutation is observed in one-thirdof PV and 15% of CIMF cases, but is practicallyabsentin ET; it is correlatedwith LOH at 9p, due to mitoticrecombinationand resultingin the duplicationof the mutantallele (uniparental disomy)(Kralovicset al., 2005). Since 2005, largeseriesof patientshavebeen testedforthe JAK2 V617F mutation,confirmingthe initially reportedfindings.The mutationhas also been found in about8%of CMML/aCML,4%of MDS (but more frequentlyin MDS with thrombocytosis),and 3% of AML patients.It seems to be restrictedto myeloid disorders inasmuchas it has so far never been found in lymphoidtumors, solid tumors,or normal tissue (Levine et al., 2005a; Steensmaet al., 2005; Ingramet al., 2006). JAK2 is a major player in hematopoiesis, and particularlyin erythropoiesis,by transmittingsignals from the receptors for several cytokines such as EPO, TPO, IL3, G-CSF, and GM-CSF, the cytoplasmicpart of which JAK2 is tetheredto. Upon ligand bindingto these receptors,and theirdimerization, a phosphorylationcascadetakes place, leadingto activationof the JAK-STAT,the PI3K,and the MAP-kinasepathway.The JAK2 mutationoccurs in the pseudokinasedomainJH2 thathas an autoinhibitoryfunction.This resultsin a gain-of-functionchange,releasingthe autoinhibitionandleadingto constitutive activityof the kinasethatwill now bindthereceptorandrecruitSTATseven in theabsenceof extracellularEPO or TPO. The gain-of-functionmutationof JAK2 is consistentwith the observationthat hematopoieticprecursorsof patientswith PV or ET, contraryto normal hematopoieticprecursors,can grow in vitro in the absence of exogenous EPO or TPO (endogenouserythroidcolony formation).This is also supportedby in vitro and in vivo studies showing that the expressionof mutantJAK2 induced EPO hypersensitivityand EPO-independentsurvivalof culturedcell lines expressingthe EPO-R(Jameset al., 2005; Levine et al., 2005b). Moreover,transplantation of hematopoieticstem cells carryingthe JAK2 V617F mutantin lethallyirradiatedwild-typemice inducedsubstantialerythrocytosis and a PV-like disease thataftersome monthscould progressto marrowfibrosis.The latter evolution was more pronouncedin some strains and minimal in others suggesting the existence of host modifiersof the phenotype(Jameset al., 2005; Lacoutet al. 2006). An intriguingquestion remains why the same JAK2 V617F mutationis so strongly associatedwith threerelatedyet distinctclinicalphenotypes,butcanalso be observed,albeit less frequently,in some other myeloid malignancies.There is strong experimentaland epidemiologicalevidencethatJAK2 V617F plays a majorrole in the developmentof PV. In

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CHRONIC MYELOPROLIFERATIVENEOPLASMS

PV, the allelic burdenis high as thereis a subpopulationthatcarriesa homozygousmutation, and this clone increases over time. Moreover, JAK2 V617F homozygosity appears to identify PV patientswith a more symptomaticmyeloproliferativedisorderbut not with increasedthrombosisrisk (Vannucchiet al., 2007). Recently,five out of the six cases of PV thatwere negativefor V617F were found to harbornovel mutantexon 12 alleles of JAK2, again underscoringthe role of constitutive JAK2 activity in this disease (Pardanani et al., 2007b; Scott et al., 2007). In contrast,in JAK2 V617F positive ET, the allelic burdenis distinctlylower with less than 5% homozygosity. Yet, here again, homozygosity predicts a more symptomatic disorderand is also associatedwith a higher risk of majorcardiovascularevents. Recent data in JAK2 V617F transgenicmice or retrovirallytransducedbone marrowtransplant models indicatethat the ratioof mutantto wild-typeJAK2 determinesthe hematological phenotype,with a lower ratio inducingan ET-like pictureand a higher ratioleading to a PV-lie phenotype(Tiedtet al., 2008). In view of the lower prevalenceof JAK2 mutationsin ET and CIMF,other signaling moleculesconvergingontotheJAK-STATsignalingpathway,ordownstreamof JAK-STAT, areunderscrutiny.So far,activatingmutationsof theTPOreceptorMPL have been foundin 10% of JAK2 V617F-negativeCIMFpatientsand in a smallerproportionof ET patients (Pardananiet al., 2006). Two mutationsof codon5 15havebeen described:MPLW5 15Land W5 15K.Expressionof MPLW5 15Lin recipientmice resultedin an MPD similarto human CIMF,includingmegakaryocytichyperplasia,reticulin fibrosis, markedthrombocytosis, and extramedullaryhematopoiesis. Last but not least, molecularinhibitorsof JAK2 suitablefor clinical use arenow being developed;in the future,specific moleculartargetedtherapymay becomeavailableforthese disorders(Pardananiet al., 2007a).

OTHER MYELOPROLIFERATIVE NEOPLASMS NonclassicMPD includesvariousclonal myeloproliferationssuch as chronicneutrophilic leukemia,chroniceosinophilicleukemididiopathichypereosinophilicsyndrome,chronic basophilic leukemia, and unclassified MPD. Mast cell disease, previously a separate category, has been reclassified under MPN in the 2008 WHO proposal (Tefferi and Vardiman,2008). A large proportionof these cases show tyrosine kinase activation as a consequence of gene fusions mediated by chromosome translocationsor deletions. The remainingcases are either reactive proliferationsor are still awaiting molecular characterization.

Chronic Neutrophilic Leukemia (CNL) Chronicneutrophilicleukemiais characterizedby matureneutrophilicleukocytosiswithless than5%immaturecells in the blood. Thereis granulocytichyperplasiain the bone marrow, butno dysplasiaorfibrosis.Splenomegalyis common.CNLis a raredisease(aboutI50cases reportedto date), median age is 67 years, and both sexes are equally affected.A clinically to AML. CML indolentchronicphaseis usuallyfollowedby accelerationandtransformation and reactiveleukocytosismust be excludedto establishthe diagnosisof CNL. Cytogenetic studies of bone marrow cells have shown an abnormalkaryotypein 23% of cases. The aberrationsinclude del(20q), del(1 Iq), trisomy 9, and trisomy 21 (Bench et al., 1998;

OTHER MYELOPROLIFERATIVE NEOPLASMS

217

Bohm et al., 2003). Interestingly,the JAKZ V617F mutationwas detectedin one of the six CNL tested (Steensmaet al.. 2005). Of note, a variantof Ph-positive,BCR-ABL-positive CML has been reportedwith peripheralblood neutrophiliasimilar to CNL and a variant e I9a2 transcriptwith a correspondingp230 fusion protein.This disordershould be considered as CML (Chapter7), not CNL.

Chronic Basophilic Leukemia (CBL) Chronicbasophilicleukemiais an extremelyraredisordercharacterized by prominentblood and bone marrowbasophiliain the absenceof a BCR-ABL gene rearrangement.The bone marrowshowsmarkeddysmegakaryopoiesisand the clinicalpresentationincludessystemic symptomsdue to releaseof basophilmediators:diarrhea,pruritus,andurticaria.Thedisease is aggressiveand may transformto AML. Until very recently,therewas no informationon clonality and cytogeneticchanges in CBL (Pardananiet al., 2003b). However, Lahortiga et al. (2008) hasnow reporteda t(4;5)(q21;q33)resultingin a PRKG2-PDGFRBfusiongene in a patientwith CBL and systemicmastocytosis(SM). This fusion gene was also described by Walz et al. (2007) in a patientwith chroniceosinophilicleukemiaand SM. Both cases respondedto imatinibtreatment.

Chronic Eosinophilic Leukemia (CEL) and Idiopathic Hypereosinophilic Syndrome (iHES) Idiopathichypereosinophilicsyndrome comprisesa spectrumof indolent to aggressive diseasescharacterizedby persistentunexplainedhypereosinophilia.The diagnosticcriteria for iHES are sustained hypereosinophilia( > 1500 x 109/L), signs of peripheralorgan damage (mainly of the heart and lungs, splenomegaly,neuropathy,skin rash, etc.), and exclusionof reactiveeosinophilia.The diagnosisof CELalso requiresthe detectionof some featureof leukemiasuchas thepresenceof anexcess of blastsin thebone marroworbloodor evidenceof clonalityseen cytogeneticallyorby molecularmethods.Usuallythe diagnosisis establishedonly afterexclusion of an extensivelist of possible underlyingconditionsthat can cause eosinophilia, like T-cell-mediated HES, malignancies that induce reactive nonclonaleosinophilia,andothermyeloproliferativedisordersin which clonal eosinophilia can be partof the hematologicalphenotype(AML with inv( I6), CML,PV, ET, and CMF) (Gotlib, 2005). ldiopathichypereosinophilicsyndromekhroniceosinophilicleukemiais a raredisease thatpredominantlyaffectsyoung to middle-agedmales and has a meandurationof 5 years (range 1-24 years). Causes of death are related to organ damage with congestive heart failure, thrombo-embolicevents, or leukemic progression.Using chromosomebanding cytogenetics,only 15%of iHES/CELpatientsshow an abnormalkaryotypewith generally myeloid neoplasia-specificaberrationssuch as +8 (most frequent),-7, i( 17q), del(20q), and -Y (Bain,2003; Gotlib,2005). Reciprocalbalancedtranslocationshavebeen reported in single cases with breakpointsat 4q12, the site of the PDGFRA gene (see Table 8.2). By far the most frequentaberrationin CEL is a cryptic deletion at 4q12 that can be demonstratedusing FISH(Coolset al., 2003; Pardananiet al., 2003a) (Fig. 8.2). This 800 kb deletion fuses the 5' partof a newly describedhumangene FZf ILl and the 3' partof the PDGFRA gene to encode the novel fusion tyrosinekinase FIPlL1 -PDGFRA.The breakpointsare scatteredin FIPlLl butrestrictedto exon 12 in PDGFRA;the fusion is alwaysin frameandeasily detectedby RT-PCR.FIPlLl-PDGFRAis a constitutivelyactivetyrosine

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CHRONIC MYELOPROLIFERATIVE NEOPLASMS

TABLE 8.2 Fusion Genes Resulting in Activation of Tyrosine Kinases in BCR-ABLNegative Myeloproliferative Disorders ~

Cytogenetics

Fusion Gene

Phenotype’

Reference

(A) JAK2 (9~241 t(9;22)(~24;qI1) t(8;9)(~22;~24) t(9;12)(p24;p13)

BCR-JAK2 PCMI-JAK2 ETV6-JAKZ

uMPD uMPDlAML AML/ALL/uMPD

Griesingeret al. (2005) Reiter et al. (2005) Peeters et al. (1997)

(B) PDGFRA (4q 12) del(4)(q 12q12), FIPILI-PDGFRA cryptic t(4;22)(qI2;q1 I ) BCR-PDGFRA t(4;iO)(q12;p11) KlFSB-PDGFRA ins(9;4)(q33;ql2q25)CDSRAP2-PDGFRA ETV6-PDGFRA STRN-PDGFRA

CELfSM

Cools et al. (2003)

aCML/SM CEL CEL CEL CEL

Baxteret al. (2002) Score et al. (2006) Walz et al. (2006) Curtiset al. (2007) Curtiset al. (2007)

(C) PDGFRB (Sq33) ETVbPDGFRB t(5;12)(q33;pl3) RABAPTIN5-PDGFRB t(5;17)(q33;p13) t(5;17)(q33;p1 I .2) HCMOGTI-PDGFRB CEV14-PDGFRB t(5;14)(q33;q32) t(5;14)(q33;q24) NlN-PDGFRB KlAAI.509-PDGFRB t(5;14)(q33;q32) TPS3BPI-PDGFRB t(5;15)(q33;q22) PDE4DIP-PDGFRB t(l;5)(q23;q33) HIPI-PDGFRB t(5;7)(q33;qll.2) H4-PDGFRB t(5; lO)(q33;q21) TPM3-PDGFRB t(l;5)(q22;q33) t(5;16)(q33;pl3) NDEI-PDGFRB t(5:I 2)(q33;q24) GITZ-PDGFRB t(i ;5; I 1 j(?;q33;pi3) CPIAPI-PDGFRB t(4;5;5)(q2I ;q3l;q33)PRKGZ-PDCFRB t(4;5)(q21;q33) PRKCZ-PDGFRB

CMML + eosinophilia CMML CMML + eosinophilia AML eosinophilia uMPD eosinophilia CMML eosinophilia uMPD + eosinophilia uh4PD + eosinophilia CMML eosinophilia uMPD CEL CMML uMPD eosinophilia CEL CEL + SM CBL + SM

Golub et al. ( 1 994) Magnussonet al. (2001) Morerioet al. (2004) Abe et al. (1997) Vizmanoset al. (2004) Levine et al. (200%) Grandet al. (2004b) Wilkinson et al. (2003) Ross et al. (1998) Schwalleret al. (2001) Rosati et al. (2006b) Rosati et al. (2006a) Walz et al. (2007) Walz et al. (2007) Walz et al. (2007) Lahortigaet al. (2008)

ZNFl98-FGFRI ‘ FOP-FG FRI CEPIlO-FGFRI TRiM24-FGFRl FGFRIOP2-FGFRI

EMS EMS EMS EMS EMS

Reiter et al. (1998) Popovici et al. (1999) Guasch et al. (2000) Belloni el al. (2005) Grandet al. (2004a)

MYOAIS-FGFR 1 HERVK-FGFRI BCR-FGFRI

EMS EMS CML-like disease

Walz et al. (2005) Guasch el al. (2003) Fioretoset al. (2001)

(D) FGFRI (8pll) t(8;13)(pll;q 12) t(6;8)(q27;pll) t(8;9)(plI;q33) t(7;8)(q32;pII ) ins( 12;8) (p I 1 :pl lp22) t(8;17)(pl1;q I I ) t(8;19)(pIl;q13.3) t(8;22)(pll;qII )

+ + +

+

+

“ALL, acute lymphoblasticleukemia: AML, acute myeloid leukemia;CML, chronic myeloid leukemia;aCML, atypicalCML; CMML, chronic myelomonocytic leukemia;CEL, chroniceosinophilic leukemia;CBL, chronic basophilicleukemia:JMML,juvenilemyelomonocytic leukemia;uMPD, unclassifiedmydoproliferativedisorder; EMS, 8pl I myeloproliferativesyndrome;SM, systemic mastocytosis.

OTHER MYELOPROLIFERATIVENEOPLASMS

CEN RP! 3-42OK76

(4

FIPfL 1

-

RP113H20

CHIC2 PDGFRA

-

-

KIT

219

TEL

RPII-24010

100 Id,

FIGURE 8.2 FISH detection of the 4q12 deletion associated with the FZPILI-PDCFRA fusion. Genomic map with the FISH probes (a) and examples of three-colorFISH analysis performed on a control sample (b), and two patients(c/d-e). A map of the 4q 12 region, with relevantgenes and selected FISH probes, is drawn to scale. Note loss of the 3H20 (green) signal in c-e. (e) Arrow indicates a seemingly normal looking chromosome 4 with the cryptic del(4)(q 12) (reprint with permission from Leukerniu). (See the color version of this figure in Color Plates section.)

kinase thatphosphorylatesitself and STAT-5. The mechanismof activationis not dimerizationdependentbut involves the disruptionof the juxtamembranedomainof PDGFRA that mediatesautoinhibitionof the PDGFXA cytoplasmicportion(Stoveret.al., 2006). The del(4)(q12ql2)IFIPlLl-PDGFRAfusion is found in 4 0 4 0 % of CEL patients.It cosegregateswith a homogeneousclinical phenotypethat includes splenomegaly,tissue fibrosis,increasedserumtryptaseandcyanocobalaninlevel, high riskof cardiaclesions,and thrombo-embolicevents (Klion et al., 2003; Vandenbergheet al., 2004). The FZPILIPDGFRA fusion has also been found in a subset of patients with SM and eosinophilia (Pardananiet al., 2003a). The fusion is presentin all myeloid lineages but eosinophilsare particularlysensitiveto the proliferativesignal.The majorinterestin identifyingFZPlLlPDGFRA positive CEL is its excellent response to imatinib;rapidcomplete and durable hematologic and molecular responses are obtained with doses of 100-400 mg daily (Jovanovicet al., 2007). Secondaryresistanceto imatinibis extremelyrareand associated with progressionto acuteeosinophilicleukemia.The mechanismof resistanceis based on the selection for or emergenceof a T674I kinase domainmutantof FIPILI-PDGFRB. A fraction of FZPILI-PDGFRA-negative CEL is also responsive to imatinib,which stronglysuggeststhatalso in thesecases, a yet unidentifiedtargetof imatinibis responsible for the disease. Among these, some alternativefusion genes involving PDGFRA or PDGFRB have been identified. Three patients with a t(4;22)(q12;qll) encoding a BCR-PDGFRA gene fusion have been reported.They presented with atypical CML features, splenomegaly,and prominenteosinophilia (Baxter et al., 2002). Other single cases with translocationsinvolving4q12 have also been reported.The patientswere male, presentedwith CEL, andrespondedto imatinibtreatment.Thevariousgene fusionsresulted

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in tyrosinekinaseactivationthroughaffectionof the oligomerizationdomainof the partner genes (Table 8.2).

Chronic MPD Associated with PDGFRB (5q33) Fusion Genes Due to Translocations The firsttranslocationinvolvingPDGFRB was a t(5;I2)(q33;p13)encodinga fusionprotein ETVbPDGFRB(Golubet al., 1994) (Fig, 8.1). The patientspresentedwith CMMLwith prominenteosinophilia.Variantsof these translocationshavebeen reported,mostly in only one or a few patientseach. The phenotypeis invariablychronic uMPD or CMML with eosinophilia.They havevariablesplenomegalyand marrowfibrosis.Two patientspresented with CELandSM. TheseMPD patientsaremainlymales.Theyhavea poorprognosiswitha mediansurvivalof 2 yearsafterconventionaltherapy.Whentested,thesecases respondedto imatinib,which has thereforethe potentialto improveoutcome. Currently,15 partnergenes have been identified.These areETV6 (TEL, 12pI3), TRIP1 1 (CEV14, 14q32), HZPf (7qll), CCDC6 (H4, 1Oq21), RABEPI (RABAPTZN5, 17p13), PDE4DIP (lq23), SPECCl (HCMOGT-I, 17pl l), NIN (14q24), KIM1509 (14q32), TP53BPI (15q22), NDEl (16~13).TPM3(lq22), GIT2 (12q24), GPIAPI (llp13), and PRKG2 (4q21) (Table 8.2). As a resultof the translocation,the fusion proteinexhibitsconstitutivetyrosinekinase activationdueto oligomerizationmotifspresentin the partnergene.Cell linetransformation and MPD inductionin mice have been demonstrated(Magnussonet al., 2001; Schwaller et al., 2001). Finally, it shouldbe mentionedthatthe chromosomalbreakpointin 5q has not always been interpretedas 5q33 but was more broadlymappedto the 5q31-33 region. However, dualcolorFISHanalysiswith probesforPDGFRB can resolvethebreakpointpositioneven in cases with complex karyotypes.

8pll MyeloproliferativeSyndrome (EMS) 8 p l l myeloproliferativesyndrome (EMS) (also called stem cell leukemicflymphoma syndrome,SCLL)constitutesa clinical phenotypewith featuresof botheosinophilicMPD and lymphoma,and is molecularlycharacterizedby a fusion gene thatinvolvesthe FGFRI (fibroblastgrowthfactor receptor1) gene in 8 p l l . EMS is extremelyrare,with a median patientage of 32 yearsand with a slight male predominance(M3/F2). Clinicalfeaturesare eosinophilia,myeloid hyperplasiain the bone marrow,splenomegaly,anda strikinglyhigh incidence of lymphomaeither of B- or, more commonly, T-cell phenotype(Macdonald et al., 2002). Lymphadenopathymay be present at diagnosis or develop later. Rapid transformationto acute leukemia,mostly AML, occurswithin 1 or 2 yearsfrom diagnosis (median6-9 months).Both myeloid and lymphoidlineage cells exhibit the 8pl1 translocation, demonstratingthe stem cell origin of the disease. Varioustranslocationshave been reportedand characterized.The most frequentis the t(8;13)(pl l;q12) resultingin ZNF198-FGFRI gene fusion (Reiteret al., 1998) (Fig. 8.1). Others are t(6;8)(q27;pll), t(8;9)(p1l;q33), t(8;22)(pll;qll). as well as four more (Table8.2). In all characterizedcases, the tyrosinekinase domainof FGFR1 is juxtaposed to a dimerizationdomainof the partnergene, resultingin constitutiveactivationof FGFRZ. Some of the fusion mutantshave been shown to transformcell lines or induce EMS-like disease in mice (Guaschet al., 2004).

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DifferentFGFRIpartnergenes may be associatedwith subtlydifferentphenotypes.For example,twocases of t(6;8) wereinitiallydiagnosedwith PV. Thrombocytosisis frequently associated with t(8;9). The incidence of T-cell non-Hodgkinlymphomais considerably higherin patientswith t(8;13) comparedto patientswith varianttranslocations.The t(8;22) encoding a BCR-FGFRl fusion protein often leads to a CML-like disease (Cross and Reiter,2002). Imatinibis inactiveagainstdisease broughtaboutby FGFRIrearrangement, but other compoundshave shown activity in vitro and are candidatesfor targetedtherapyof EMS patients.

Systemic Mastocytosis (SM) Systemicmastocytosisis characterizedby abnormalgrowthandaccumulationof mastcells in one or more organ systems including the bone marrow.As mast cells arise from hematopoieticstem cells and shareseveralfeatureswith basophils,SM is often considered as trueMPD with specificclinical presentation.The symptomsaredue to organinvasionon the one hand, inducingosteoporosis,hepatomegaly,ascites, and cytopenia,and release of mast cell mediatorson the other, leading to diarrhea,urticaria,pruritus,flushing, and syncope.The clinical coursecanbe indolentoraggressive,associatedwith anotherMPD or with mast cell leukemia. Cytogenetic data are scarce. Trisomy for chromosomes 8, 9, and 14, deletions of chromosome arms 7q, 114. and 20q, and translocationsas well as other structural changes involving chromosome4 have occasionallybeen reported(Swolin et al., 2000, 2002). A largefractionof SMcases havepointmutationsof theKITgenein 4q 12. Most frequent is the mutation D816V in exon 17 in the activationloop of the kinase domain of KIT. Mutationsin exon 10or 11 arealso foundandaretherapeuticallyrelevantbecausethe latter patientsmay benefitfromimatinibtreatmentwhereasthosewith a D816V mutantdo not and other inhibitors must be used (Longley et al., 1996; Ma et al., 2002; Garcia-Montero et al., 2006). KITmutationsarealso the primarychangein gastrointestinalstromaltumor,a mastcell-derivedtumor,andthey may be a secondarychangein some AML with t(8;21) or inv(16) as the primaryabnormality.In addition,Steensmaet al. (2005) identifieda JAK2 V617F mutationin two of eight SM cases without KITmutation. Interestingly,some cases of CEL with FZPILI -PDGFRA-rearrangements presentwith eosinophilia and increased numbers of mast cells and may have some of the typical manifestationsof SM (Pardananiet a]., 2003a).

MYELOPROLIFERATIVESYNDROMES IN CHILDHOOD Myelodysplasticsyndromesand myeloproliferativesyndromesof childhoodare a heterogeneous groupof clonal disordersof hematopoiesiswith overlappingclinical featuresand inconsistentnomenclature(Luna-Finemanet al., 1999). It has thereforebeen suggestedthat sporadicmyeloproliferativedisordersin childrenrequirea specific set of diagnosticcriteria (Teofili et al., 2007). tn a series of 167 pediatricpatientswith myeloproliferativeor myelodysplasticsyndromes (Luna-Finemanet al., 1999), almost one-thirdhad an associated constitutional disorder.About two-thirdshad adult-typemyelodysplasticsyndrome,60 had JMML, and

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six had transientmyeloproliferativedisorder(TMPD). Monosomy 7 or del(7q) were the most common cytogenetic aberrationsseen mainly in patients with M D S or JMML. Progressionto leukemictransformation was frequent,usuallywithin2 yearsof diagnosis, and survivalwas poor. Familial monosomy 7 syndrome is a characteristic,acquiredmyeloproliferativedisorder in childhood.The diseasemostly affects boys and,remarkably,can occurin sibs (Baranger et al., 1990, Daghistani et al., 1990). The clinical presentationresembles JMML and is characterizedby repeated infectious episodes, hepatosplenomegaly,and progressionto AML. Hematologic featuresare anemia, thrombocytopenia,and leukacytosis. There is monosomy7 in all lineages,indicatinga stemcell disorder.So far,thereareno clues why this syndromewith acquiredmonosomy 7 occursin sibs (Shannonet al., 1992), but a familial mutatorgene mightpredispose.Indeed,monosomy7 is known as a “cytogeneticopportunist” occurringin patients susceptible to myeloid leukemia because of various genetic predispositions,includingFanconi’sanemia,neurofibromatosistype 1, familialleukemia, and severe congenitalneutropenia(Luna-Finemanet al., 1999). Transient myeloproliferative disorder is a leukemoid reaction during the neonatal period frequentlyseen in childrenwith Down’s syndromewith constitutionaltrisomy21 (Zipursky, 2003). It is exceptional in normal children. TMPD mimics a congenital megakaryoblasticleukemiaat disease onset, but insteadof takinga fatalcourse,it usually resolves graduallyover a period of days to months,even withoutantileukemictreatment. In 25% of the cases, it progresses or relapses to acute megakaryoblasticleukemia (AMKL) by the age of 3 years. Cytogenetic analyses have revealed an extra acquired chromosome21 in the leukemoidblasts of these patients,both in phenotypicallynormal childrenand in patientswith Down’s syndrome;the latterthus may have tetrasomy21 in the bone marrowcells (Abe et al., 1989; Faed et al., 1990). Almost all patients with TMPDor TMPD-derivedAMKL have somatic GATAZ mutationsthatpossibly may have been acquiredin utero (Carpenteret al., 2005). GATAI is a zinc finger transcription factor essential for erythropoiesisand the maturationof megakaryocytes.It seems that both exon 2 GATAI mutationand trisomy 21 in hematopoieticprogenitorsare required for TMPD to develop. Overexpressionof RUNX 1 (AML1 , 2lq22) has been suggestedto play a role as it is an essential transcriptionfactor for terminal differentiationof megakaryocytes(Xu et al., 2006). Why the disease is transientin some patients,remains unclear. JMMLbelongsto the MDS with myeloproliferative featuresandis discussedin Chapter6. P V and ET are extremely rare in childhood but when they occur in the young, they are more often familial than when occurring in adult patients. Mutationsof the EPO receptor, the T P O gene and its receptor MPL, and the VHL gene have been reportedin a minority of familial PV or ET (Kralovics et al.. 1997; Ang et al., 2002; Pastoreet al., 2003; Ding et al., 2004). Childhoodfamilial ET cases exhibit polyclonal hematopoiesis, are wild-type JAK2, and positive for MPL mutation (Teofili et al., 2007). SporadicPV in childrenshows PRV1 overexpressionbut the JAK2 V6Z7Fis detectedin only one-thirdof all cases, which suggeststhatthey acquirethe mutationlateron when the disease progressesor thatothergenetic defects are associatedwith the disease (BellanneChantelotet al., 2006). Mutationsof the VHL gene may representan importantcause of sporadicpediatricpolycythemiaswith an inappropriatelyhigh serumEPO concentration (Pastoreet al., 2003). Childrenwith PV and ET have a significantlylower incidence of thrombosisthan do adults(Teofili et al., 2007).

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CLINICAL CORRELATIONS Cytogeneticaberrationsare foundin a minorfractionof cases of classic MPN at diagnosis; they aremorecommonin PVandCIMFbut unusualin ET. Commonchanges,thatis, 2Oq-, 13q-, f8, +9, and gain of Iq, are found in 80%of patientswith an abnormalkaryotype. This underscoresthe close pathogeneticrelationshipamongthe threediseases PV,CIMF, and ET. Cytogeneticshas been instrumentalin unequivocallydemonstratingMPN as clonal neoplastic disordersby detecting aberrationsin all myeloid lineage elements, including extramedullaryhematopoiesis,butnot in the reactivefibroblastproliferationthatoccursin CIMFand spentPVandET (Jacobsonet al., 1978;Wanget al., 1992).In severalstudies,the prognosisof MPD patientswas not found to be influencedby the presenceof a cytogenetically abnormalclone at diagnosis(Swolin et al., 1988;Aatolaet al., 1992; Campbelland Garson,1994). However,otherstudies have suggesteda shortersurvivalfor patientswho had initial karyotypicabnormalities(Diez-Martinet al., 1991; Reilly et al., 1997). More recently, Tefferi et al. (2001) reportedthat +8 and 12p- were unfavorableprognostic indicatorsin CIMF,whereas20q- and 13q- had no impact on survival. Acquisition of cytogenetic aberrationsduring disease evolution may be part of the naturalhistoryof these diseasesbutcould also be linkedto the use of myelotoxictreatment. Abnormalitiesin PVareobservedin 13-1 8%of cases at diagnosisprogressingto 56450% in treatedpatients(Rege-Cambrinet al., 1987;Diez-Martinet al., 1991;Tothovaet al., 2001). Theseacquiredaberrationsfrequentlyinvolvechromosomes5,7,and 17,often in a complex karyotype. They are associated with a higher probabilityof early death either from progressionto leukemiaor from complicationsrelatedto hematopoieticdysfunction. The role of cytogenetics in the modem diagnosticworkupof MPN lies mainly in the exclusionof a Philadelphiachromosomeand,to a lesserextent,in the identificationof rare translocationspointing to specific molecularclinico-biologicalentities among the MPN, requiring specific therapeuticapproaches.Indeed, imatinib, the first tyrosine kinase inhibitorused successfully in CML, is also very effective in inducinghematologicaland even molecular responses in MPD and CEL characterizedby fusion genes involving P D G F M Breceptors,KIT wild-typeor specific KIT mutations.Diseases characterizedby KIT exon 17 mutation (the most frequent),JAK2 mutation,and FGFRI fusions do not respond to imatinib. However, numerousother inhibitorsare being tested and should become availablein the nearfuture.Finally,cytogeneticsstill has a role in the identification of complex karyotypesindicatingadvanced disease with probably a more unfavorable prognosis. The importanceof cytogeneticsas an indicatorof clonality in the diagnosticphase of BCR-ABL-negativeMPN is diminishing.Since 2005, JAK2 V617F appearsto be for PV the equivalentof BCR-ABL for CML:a molecularmarkerpresentin almost 100%of the cases, which has become the targetfor demonstrationof clonality.This somehow also appliesto ET and CIMF,in view of the substantialincidenceof the JAK2 V617F mutationin these diseases. In CIMF, the “clonal” yield of cytogenetics remains substantial,justifying cytogenetic examinationfor this purpose alone. In ET, on the other hand, cytogenetic investigationsonly seldom detect clonal expansions. Thereis strongevidencefromstudieson mice thatJAK2 V6I7F plays a majorrole in the pathogenesisof PVandET (Jameset al., 2005;Lacoutet al., 2006;Tiedtet al., 2008). JAK2 V617F homozygosityis associatedwith moreadvancedandsymptomaticdiseasein PVand with higher frequencyof thromboticevents in ET (Vannucchiet al., 2007). A dosage hypothesis has been put forwardto the effect that low levels of kinase activity favor a

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thrombocyticphenotype, whereas higher levels lead to an erythrocyticphenotype or a myelofibroticstate,butthe detailsof this hypothesisstill need to be elucidated.Additional molecularevents as well as chromosomeabnormalitiesand host modifierpolymorphisms may also play a role. In CIMF,Campbellet al. (2006) reporteda poorersurvivalassociated with the mutation. Finally, the adventof additionaltypes of targetedtherapyin the nearfuture,therapies based on our increasinglydetailedmolecularknowledgeof essentialpathogeneticdisease features,will hopefully improveoutcome in the years to come, like imatinibhas already done for CML.

SUMMARY Followingthe paradigmof CMLandthe BCR-ABL fusionkinase,also BCR-ABL negative myeloproliferativeneoplasms have recently been established as diseases caused by inappropriately active tyrosinekinases, the constitutiveactivationof which is responsible for the hypersensitivityof myeloid progenitorsto, or even theirindependencefrom, the growthfactorsthatnormallyregulatecell growthandsurvival.For a long time, cytogenetic analysisconstitutedone of the few approachesto demonstrateclonality,althoughthe yield was low in MPN, especially in ET and iHES/CEL.The JAK2 V617F mutationand the FIPlLl-PDGFRA fusion gene arerecently discoveredmolecularmarkersthat cannotbe detectedby chromosomebandinganalysis.Theyhaverapidlybecomethemarkersof choice to demonstrateclonalityin PV, CIMF,andET (forJAK2) andCEL(forFZP1LI-PDGFRA). In this respect,the importanceof cytogeneticanalysisin the demonstrationof clonality in the diagnostic phase is diminishing, although a role in unmutatedJAK2 or FIPILIPDGFRA-negativedisease remains. In addition,it remainsof prime importanceto rule out Ph-positiveCML. Finally,cytogeneticanalysis may reveal fusion genes that identify raremyeloproliferativediseases with a specific biological behavior,for example,t(5;12)positive chronic myelomonocyticleukemia with eosinophilia,diseases that requirededicatedand specific moleculartherapy.The clinical historyand state-of-the-arttreatmentof patientswith these diseases are likely to be modifiedby the introductionof novel, specific targetedtherapiesthat are now on the horizon.

ACKNOWLEDGMENTS This work was supportedby grantsfrom FWO-Vlaanderen,by the InteruniversityAttraction Poles ( U P ) grantedbythe FederalOffice forScientific,Technicaland CulturalAffairs, and by a ConcertedAction Grantfrom the CatholicUniversity,Leuven.

REFERENCES Aatola M, Armstrong E, Teerenhovi L. Borgstrijm GH (1992):Clinical significance of the del(20q) chromosome in hematologic disorders. Cancer Genet Cytogenet 62:75-80. Abe K, Kajii T, Niikawa N (1989): Disomic homozygosity in 21-trisomic cells: a mechanism responsible for transient myeloproliferative syndrome. Hum Genet 8 2 3 13-3 16.

REFERENCES

225

Abe A, Emi N, TanimotoM, TerasakiH, MarunouchiT, SaitoH (I 997): Fusionof the platelet-derived growth factorreceptorbeta to a novel gene CEVI4 in acute myelogenousleukemiaafterclonal evolution.Blood 90:427 1-4277. AI Assar 0, u1-HassanA, Brown R, Wilson GA, HammondDW, Reilly JT(2005): Gainson 9p are common genomic aberrationsin idiopathicm yelofibrosis: a comparativegenomic hybridization study. Br J Haemalol 129:6&7 1. Andrieux J, Demory JL, Morel P, PlantierI, Dupriez B, Caulier MT, Bauters F, Lai JL (2002): Frequencyof structuralabnormalitiesof the long arm of chromosome12 in myelofibrosis with myeloid metaplasia.Cancer Genet Cylogenet 137:68-7 1. AndrieuxJ, Demory JL, DupriezB, Quief S, PlantierI, RoumierC, BautersF, Lai JL, KerckaertJP (2004): Dysregulationandoverexpressionof HMGA2 in myelofibrosiswith myeloid metaplasia. Genes Chromosomes Cancer 39:82-87. AndrieuxJ, Roche-LestienneC, Geffroy S, DesterkeC, GrardelN, Plantier1, SelleslagD, DemoryJL, Lai JL, Leleu X, Bousse-KerdilesC, VandenbergheP (2007): Bone morphogenetic protein antagonist gene NOG is involved in myeloproliferativedisease associated with myelofibrosis. Cancer Genet Cylogenet 178:11-16. Ang SO, Chen H, HirotaK, GordeukVR, JelinekJ, Guan Y,Liu E, SergueevaAI, MiasnikovaGY, T (2002): Disruption of oxygen Mole D, Maxwell PH. Stockton DW, Semenza GL, Prchal J homeostasisunderliescongenitalChuvashpolycythemia.Nut Genet 3 2 6 14-621. Bacher U, Haferlach T, Kern W, HiddemannW, SchnittgerS, Schoch C (2005): Conventional cytogeneticsof myeloproliferativediseases otherthan CML contributevalid information.Ann Hema to1 84:250-257. Bain BJ (2003):Cytogeneticandmoleculargeneticaspectsof eosinophilicleukaemias.Br JHaematol 122:173-179. BarangerL, Baruchel A, Leverger G, Schaison G, Berger R (1990): Monosomy-7 in childhood hemopoietic disorders.Leukemia 4:345-349. BaxterEJ, HochhausA, BoluferP, ReiterA, FemandezJM, SenentL, CerveraJ. MoscardoF, Sanz MA, CrossNC (2002): The t(4;22)(q12;ql 1) in atypicalchronicmyeloid Ieukaemiafuses BCR to PDGFRA. Hum Mol Genet 11:1391-1397. BaxterEl,ScottLM, CampbellPJ, East C, FourouclasN, SwantonS, Vassiliou GS, Bench AJ, Boyd EM, CurtinN, Scott MA, ErberWN, GreenAR (2005): Acquiredmutationof the tyrosinekinase JAK2 in humanmyeloproliferativedisorders.Lancet 365:1054-106 I . Bellanne-Chantelot C, ChaumarelI, LabopinM,BellangerF, BarbuV,De TomaC, DelhommeauF, CasadevallN, VainchenkerW, ThomasG, NajmanA (2006): Geneticandclinical implicationsof the Val6 I7Phe JAK2 mutationin 72 families with myeloproliferativedisorders.Blood 108: 346-352. Belloni E, TrubiaM,GaspariniP, Micucci C, TapinassiC, ConfalonieriS, Nuciforo P, MartinoB, F,Pelicci PG,Di Fiore PP (2005): 8p11 myeloproliferativesyndromewith a novel t(7;8) Lo-COCO translocationleading to fusion of the FGFRL and TIFl genes. Genes Chromosomes Cancer 42:320-325. Bench AJ. Pahl HL (2005):Chromosomalabnormalitiesandmolecularmarkersin myeloproliferative disorders.Semin Hematol42:196-205. Bench AJ, Nacheva EP, ChampionKM, Green AR (1 998): Moleculargenetics andcytogeneticsof myeloproliferativedisorders.Baillieres Clin Haematol 1 1:8 19-848. Bench GI,Nacheva EP, Hood TL, HoldenJL,FrenchL. SwantonS, ChampionKh4, Li I, WhittakerP. StavridesG, Hunt AR, Huntly BJ, Campbell LJ, Bentley DR, DeloukasP, Green AR (2000): Chromosome20 deletions in myeloid malignancies: reductionof the common deleted region, generationof a PAClBAC contig and identificationof candidategenes. UK CancerCytogenetics Group(UKCCG). Oncogene 19:3902-3913.

226

CHRONIC MYELOPROLIFERATIVE NEOPLASMS

Berger R, Bernheim A, Le Coniat M, Vecchione D, Flandnn G, Dresch C, Najean Y (1984): Chromosomestudiesin polycythemiaVera patients.Cancer Genet Cytogenet 12:217-223. Bohm J, Kock S, Schaefer HE, Fisch P (2003): Evidence of clonality in chronic neutrophilic leukaemia.J Clin Pathol56292-295. Busson M,RomanaS, Nguyen KhacF, Bernard0,BergerR (2004):Cryptictranslocationsinvolving chromosome20 in polycythemia Vera. Ann Genet 47:365-371. Campbell W,Carson OM (1994): The prognostic significance of deletion of the long arm of chromosome20 in myeloid disorders.Leukemia 8:67-71. Campbell PJ, GriesshammerM, Dohner K, Dohner H, Kusec R, Hasselbalch HC, Larsen TS. PallisgaardN, GiraudierS, Bousse-KerdilesMC, DesterkeC, GuertonB, DupriezB, Bordessoule D, FenauxP, KiladjianJJ. ViallardJF,BriereJ, HarrisonCN, GreenAR, Reilly JT(2006):V617F mutation in JAK2 is associated with poorer survival in idiopathic myelofibrosis. Blood

I07:2O98-21OO. CarpenterE, Valverde-GardunoV, SternbergA, Mitchell C, RobertsI, Vyas P, VoraA (2005):GATAl mutationand trisomy 21 are requiredonly in haematopoieticcells for developmentof transient myeloproliferativedisorder.Br J Haematol 128548-55 1 . Chen Z,NotohamiprodjoM, GuanXU,PaiettaE, Blackwell S, StoutK, TurnerA, RichkindK, Trent JM, LambA, SandbergA4 (1 998): Gainof 9p in the pathogenesisof polycythemia Vera. Genes Chromosomes Cancer 22:321-324. Cools J, DeAngelo DJ, GotlibJ, StoverEH,LegareRD, CortesJ, KutokJ,ClarkJ, GalinskyI, Griffin JD, Cross NC, Tefferi A, MaloneJ, Alam R, SchrierSL, Schmid J, Rose M, VandenbergheP, VerhoefG, BoogaertsM, WlodarskaI, KantarjianH, MarynenP, CoutreSE, StoneR, GillilandDG (2003):A tyrosinekinase createdby fusion of the PDGFRA and FIPlL1 gcnes as a therapeutic targetof imatinibin idiopathichypereosinophilicsyndrome.N Engf J Med 348:1201-1214. Cross NC, Reiter A (2002): Tyrosine kinase fusion genes in chronic myeloproliferativediseases. Leukemia 16:1207-1212. CurtisCE,GrandFH, MustoP, ClarkA, MurphyJ, PerlaG, MinerviniMM, StewartJ, ReiterA, Cross NC (2007): "bo novel imatinib-responsivePDGFRA fusion genes in chronic eosinophilic leukaemia.Br JHaematolI38:77-81. DaghistaniD, Toledano SR, Curless R (1990):Monosomy 7 syndrome.Clinical heterogeneity in childrenand adolescents.Cancer Genel Cytogenet 44:263-269. Demory JL, Dupriez B, Fenaux P, Lai JL, Beuscart R, Jouet JP, Deminatti M, BautersF (1988): Cytogeneticstudiesandtheirprognosticsignificancein agnogenicmyeloid metaplasia:a reporton . 72:855-859. 47 C ~ S Blood Diez-MartinJL, Graham DL, Petitt RM, Dewald GW (1991):Chromosomestudiesin 104 patients with polycythemiaVera. Mayo Clin Proc 66:287-299. Ding J, KomatsuH,WakitaA, Kato-UranishiM, [to M, SatohA, TsuboiK, Nitta M, MiyazakiH, Iida S, Ueda R (2004): Familial essential thrombocythemiaassociated with a dominant-positive activatingmutationof the c-MPLgene, which encodesfor the receptorfor thrombopoietin.Blood

103:41984200. Dingli D, GrandFH, Mahaffey V, SpurbeckJ, Ross FM, WatmoreAE, Reilly JT,CrossNC, Dewald GW, Tefferi A (2005):Der(6)t(1 ;6)(q21-23;p21.3): a specific cytogeneticabnormalityin myelofibrosis with myeloid metaplasia.Br J Haematol 130:229-232. Dingli D, SchwagerSM, Mesa RA, Li CY, Dewald GW, Tefferi A (2006):Presenceof unfavorable cytogeneticabnormalitiesis the strongestpredictorof poor survivalin secondarymyelofibrosis. Cancer 106:1985-1989. Djordjevic V, Dencic-Fekete M, Jovanovic J, Bizic S, Jankovic G, Bogdanovic A, CemerikicMariinovic V, Gotic M (2007): Cytogenetics of agnogenic myeloid metaplasia: a study of 61 patients.Cancer Genet Cytogenet 1735742.

REFERENCES

227

Dupriez B, Morel P, Demory JL, Lai JL, Simon M, PlantierI, BautersF (I 996): Prognosticfactors in agnogenic myeloid metaplasia: a report on I95 cases with a new scoring system. Blood 88: 101 3-10 18. FaedMJ, RobertsonJ, Todd AS, SivakumaranM, Tarnow-MordiWO ( 1990):Trisomy2 1 in transient myeloproliferativedisorder.Cancer Genei Cytogenet 48:259-264. Fialkow PJ, Faguet GB, Jacobson RJ, Vaidya K, Murphy S (1981): Evidence that essential thrombocythemiais a clonal disorderwith origin in a multipotentstem cell. Blood 58:916-919. FioretosT, PanagopoulosI, Lassen C, Swedin A, Billstrom R, IsakssonM, StrombeckB, Olofsson T, Mitelman F, JohanssonB (2001): Fusion of the BCR and the fibroblastgrowth factorreceptor-I (FGFR1)genes as a resultof t(8;22)(plI;q 1 I ) in amyeloproliferativedisorder:the firstfusion gene involving BCR but not ABL. Genes Chromosomes Cancer 32:302-310. Garcia-MonteroAC, Jara-AcevedoM, Teodosio C, Sanchez ML, Nunez R, PradosA, AldanondoI, Sanchez L, Dominguez M, Botana LM, Sanchez-JimenezF, Sotlar K, Almeida J, EscribanoL, OrfaoA (2006): KIT mutationin mast cells and otherbone marrowhematopoieticcell lineages in systemic mastcell disorders:aprospectivestudyof the SpanishNetworkon Mastocytosis(REMA) in a series of 1 13 patients. Blood 108:2366-2372. GolubTR, BarkerGF, LovettM, GillilandDG (1 994): Fusion of PDGFreceptorbetato a novel ets-like gene, tel, in chronic myelomonocytic leukemia with t(5;12) chromosomal translocation. Cell 77:307-3 16. Gotlib J (2005): Molecular classification and pathogenesis of eosinophilic disorders:2005 update. Arta Haematol 114:7-25. Grand EK, Grand FH, Chase AJ, Ross FM, Corcoran MM, Oscier DG, Cross NC (2004a): Identificationof a novel gene, FGFRl OP2, fused to FGFRl in 8p I I myeloproliferativesyndrome. Genes Chromosomes Cancer 40:78-83. GrandFH, BurgstallerS, KuhrT, Baxter EJ, WebersinkeG, ThalerJ, Chase AJ,Cross NC (2004b): p53-Bindingprotein 1 is fused to the platelet-derivedgrowthfactorreceptorbeta in a patientwith a t(5;I 5)(q33;q22)andan imatinib-responsiveeosinophilic myeloproliferativedisorder.Cancer Res 64:72 16-72 19. Griesinger F. Hennig H. Hillmer F, Podleschny M, Steffens R, Pies A, WormannB, Haase D, BohlanderSK (2005): A BCR-JAK2fusion gene as the resultof a t(9;22)(p24;q11.2) translocation in a patient with a clinically typical chronic myeloid leukemia. Genes Chromosomes Cancer 44:329-333. Groupe Franqaisde CytogCnCtiqueHCmatologique(1 988): Cytogenetics of acutely transformed chronicmyeloproliferativesyndromeswithouta Philadelphiachromosome.A multicenterstudyof 55 patients. Cancer Genet Cylogenei 32: 157-168. GuaschG, Mack GJ, Popovici C, DastugueN, Bimbaum D, RattnerJB, PebusqueMJ (2000): FGFRl is fused to the centrosome-associated protein CEPl10 in the 8p12 stem cell myeloproliferative disorderwith t(8;9)(pl2;q33). Blood 95: 1788-1 796. Guasch G, Popovici C, MugneretF, ChaffanetM, PontarottiP, BirnbaumD, PebusqueMJ (2003): Endogenousretroviralsequenceis fused to FGFRl kinase in the 8pl2 stem-cell myeloproliferative disorderwith t(8;19)(p12;q13.3). Blood lO1:28&288. GuaschG, Delaval B, Amoulet C, Xie MJ,XerriL, SaintyD, BirnbaumD, PebusqueMJ(2004): FOPFGFR1 tyrosine kinase, the product of a t(6;8) translocation,induces a fatal myeloproliferative disease in mice. Blood 103:309-3 12. IngramW, LeaNC,CerveraJ,GermingU, FenauxP, CassinatB, KiladjianJJ,VarkonyiJ, AntunovicP, Westwood NB, Arno MJ. Mohamedali A, Gaken J, Kontou T, Czepulkowski BH, Twine NA, TamaskaJ, Csomer J, Benedek S, GattermannN, ZippererE, Giagounidis A, Garcia-CasadoZ, Sanz G, Mufti GJ (2006): The JAK2 V617F mutationidentifiesa subgroupof h4DS patients with isolated deletion 5q and a proliferativebone marrow.Leukemia 20:13 19-1321.

228

CHRONIC MYELOPROLIFERATIVENEOPLASMS

JacobsonRJ, Salo A, Fiakow PJ ( 1978): Agnogenic myeloid metaplasia:a clonal proliferationof hematopoieticstem cells with secondarymyelofibrosis.Blood 51:189-1 94. JamesC, Vgo V, Le CouedicJP, StaerkJ, DelhommeauF, LacoutC, GarconL, RaslovaH, BergerR, Bennaceur-GriscelliA, Villeval JL, ConstantinescuSN, CasadevallN, VainchenkerW (2005): A uniqueclonal JAK2mutationleadingto constitutivesignallingcausespolycythaemiaVera.Nature 434:1144-1 148. JovanovicJV, Score J, WaghornK, Cilloni D, GottardiE, MetzgerothG, ErbenP, PoppH, Walz C, HochhausA, Roche-LestienneC, PreudhommeC. SolomonE, ApperleyJ, RondoniM, Ottaviani E, MartinelliG, Brito-BabapulleF, Saglio G, HehlmannR, Cross NC, Reiter A, GrimwadeD (2007): Low-dose imatinibmesylate leads to rapidinductionof majormolecularresponsesand achievementof completemolecularremissionin FIPlLI -PDGFRA-positivechroniceosinophilic leukemia.Blood 109:4635-4640. Klion AD, Noel P, Akin C, Law MA, Gilliland DG, Cools J, Metcalfe DD, NutmanTB (2003): Elevatedserumtryptaselevels identify a subset of patientswith a myeloproliferativevariantof idiopathic hypereosinophilicsyndrome associated with tissue fibrosis, poor prognosis, and imatinibresponsiveness.Blood 101:4660-4666. KralovicsR. IndrakK, StopkaT, BermanBW, PrchalJF, PrchalJT (1 997): Two new EPO receptor mutations:truncatedEPO receptorsare most frequentlyassociated with primaryfamilial and congenitalpolycythemias.Blood 902057-2061. KralovicsR, GuanY,PrchalJT(2002): Acquireduniparentaldisomyof chromosome9p is a frequent stem cell defect in polycythemiaVera. Exp Hematol30:229-236. KralovicsR, PassamontiF, BuserAS, Teo SS, TiedtR, PasswegJR,TichelliA, CazzolaM, SkodaRC (2005): A gain-of-functionmutationof JAK2 in myeloproliferativedisorders.N Engl J Med 352:1779-1790. La StarzaR, WlodarskaI, Aventin A, Falzetti D, Crescenzi B. Martelli MF, Van den Berghe H, MecucciC (1998): Moleculardelineationof 13qdeletionboundariesin 20 patientswith myeloid malignancies.Blood 91 :231-237. Lacout C, Pisani DF, Tulliez M, Gachelin FM, VainchenkerW, Villeval JL (2006): JAK2V617F expression in murinehematopoieticcells leads to MPD mimickinghuman PV with secondary myelofibrosis.Blood 108:1652-1660. LahortigaI, Akin C, Cools J,WilsonTM, MentensN, ArthurDC,M k c 1, Noel P, KocabasC, MarynenP, Lessin LS, WlodarskaI, RobynJ, MetcalfeDD (2008): Activity of imatinibin systemic mastocytosis with chronicbasophilicleukemia and a PRKG2-PDCFRB fusion. Haematologica 93:49-56. Lawler SD ( 1980): Cytogenetic studies in Philadelphiachromosome-negativemyeloproliferative disorders,particularlypolycythaemiarubraVera. Clin Haematol9:159-174. Levine RL,LoriauxM, HuntlyBJ, Loh ML, BeranM, StoffregenE, BergerR, ClarkJJ,Willis SG. Nguyen KT, FloresNJ, Estey E, GattermannN, ArmstrongS, Look AT, GriffinJD, BernardOA, Heinrich MC. Gilliland DG, DrukerB, Deininger MW (2005a): The JAK2 V617F activating mutationoccursin chronicmyelomonocyticleukemiaandacutemyeloidleukemia,but not in acute lymphoblasticleukemiaor chroniclymphocyticleukemia.Blood 106:3377-3379. Levine RL, WadleighM, Cools J, EbertBL, WernigG, HuntlyBJ, Boggon TJ,Wlodarska1, ClarkJJ, MooreS,AdelspergerJ, Koo S, Lee JC. GabrielS. MercherT, DAndreaA, FrohlingS, DohnerK, MarynenP, VandenbergheP, Mesa RA, TefferiA, GriffinJD, Eck MJ, Sellers WR, Meyerson M, Golub TR,Lee SJ, Gilliland DG (2005b): Activatingmutationin the tyrosinekinase JAK2 in polycythemia Vera, essential thrombocythemia,and myeloid metaplasia with myelofibrosis. Cancer Cell 7:387-397. LevineRL,WadleighM, SternbergDW, WlodarskaI, Galinsky1, StoneRM, DeAngelo DJ,Gilliland DG, Cools J (2005~):KlAA1509 is a novel PDGFRB fusion partnerin imatinib-responsive myeloproliferativedisease associatedwith a t(5;14)(q33;q32).Leukemia 19:27-30.

REFERENCES

229

Longley BJ, TyrrellL, Lu SZ, Ma YS,Langley K,Ding TG, Duffy T, Jacobs P, Tang LH, Modlin I ( 1996):Somatic c-KIT activating mutationin urticariapigmentosaand aggressive mastocytosis: establishmentof clonality in a human mast cell neoplasm. Nut Genet 12:312-314. Luna-FinemanS, ShannonKM, AtwaterSK. Davis J, MastersonM, OrtegaJ, SandersJ, SteinherzP, WeinbergV, Lange BJ ( 1999): Myelodysplastic and myeloproliferativedisordersof childhood:a study of 167 patients. Blood 93:459466. Ma Y,Zeng S, Metcalfe DD, Akin C, DimitrijevicS, ButtefieldJH, McMahonG , Longley BJ (2002): The c-KIT mutation causing human mastocytosis is resistant to ST157I and Other KIT kinase inhibitors;kinases with enzymatic site mutationsshow different inhibitorsensitivity profiles than wild-type kinases and those with regulatory-typemutations.Blood 99:174 1-1 744. MacdonaldD, ReiterA, Cross NC (2002): The 8pl I myeloproliferativesyndrome:a distinctclinical entity caused by constitutive activation of FGFXl. Arta Haematol 107:101-107. MacGroganD, Alvarez S, DeBlasio T, JhanwarSC, Nimer SD (2001): Identificationof candidate genes on chromosome band 20q 12 by physical mapping of translocationbreakpointsfound in myeloid leukemia cell lines. Oncogene 20:4150-4 160. Magnusson MK, Meade KE, Brown KE, ArthurDC, KruegerLA, BarrettAJ, Dunbar CE (2001): Rabaptin-5 is a novel fusion partnerto platelet-derivedgrowth factor beta receptor in chronic myelomonocytic leukemia. Blood 98:25 18-2525. MertensF, JohanssonB, Heim S, KristofferssonU, MitelmanF (1 99 I ): Karyotypicpatternsin chronic myeloproliferativedisorders:reporton 74 cases and review of the literature.Leukemia 5:214-220. MorerioC, AcquilaM, RosandaC, RapellaA, DufourC, Locatelli F, MaseratiE, PasqualiF, Panarello C (2004): HCMOGT-1 is a novel fusion partnerto PDGFRBin juvenile myelomonocytic leukemia with t(5;17)(q33;plI .2). Cancer Res 64:2649-2651. Nacheva E, Holloway T, CarterN, Grace C, White N, Green AR (1995): Characterizationof 20q deletions in patients with myeloproliferative disordersor myelodysplastic syndromes. Cancer Genet Cytogenet 80:87-94. Najfeld V, Montella L, Scalise A, FruchtmanS (2002): Exploring polycythaemia Vera with fluorescence in situ hybridization:additionalcryptic9p is the most frequentabnormalitydetected. Br J Haematol 119:558-566. PardananiA, KetterlingRP, BrockmanSR, FlynnHC, PaternosterSF, ShearerBM, ReederTL, Li CY, CrossNC, Cools J, Gilliland DG, Dewald GW, TefferiA (2003a): CHIC2deletion,a surrogatefor FIPILI-PDCFRA fusion, occurs in systemic mastocytosis associated with eosinophilia and predicts response to imatinib mesylate therapy.Blood 102:3093-3096. PardananiAD, Morice WG, Hoyer JD, Tefferi A (2003b): Chronic basophilic leukemia: a distinct clinico-pathologic entity? Eur J Haematol7 1:18-22. PardananiAD, Levine RL, Lasho T, Pikman Y, Mesa RA, Wadleigh M, Steensma DP, Elliott MA, WolanskyjAP. Hogan WJ, McClureRF, Litzow MR, Gilliland DG,Tefferi A (2006): MPL515 mutations in myeloproliferative and other myeloid disorders: a study of 1 1 82 patients. Blood 108~3472-3476. PardananiA, Hood J, LashoT, Levine RL, MartinMB, NoronhaG , FinkeC, Mak CC, Mesa R, Zhu H, Sol1 R, Gilliland DG, Tefferi A (2007a): TGlO1209, a small molecule JAK2-selective kinase inhibitorpotentlyinhibitsmyeloproliferativedisorder-associatedJAK2V617Fand MPLW5I5L/K mutations.Leukemia 2 I :1658- 1668. PardananiA, Lasho TL, Finke C, Hanson CA, Tefferi A (2007b): Prevalence and clinicopathologic correlates of JAK2 exon 12 mutations in JAK2V617F-negative polycythemia Vera. Leukemia 21 :1960-1 963. PastoreC, Nomdedeu J, Volpe G, GuerrasioA, Rege-CambrinG, ParvisG, PautassoM, Daglio C, Mazza U. Saglio G (1995): Genetic analysis of chromosome 13 deletions in BCWABL negative chronic myeloproliferativedisorders. Genes Chromosomes Cancer 1 4 106-1 1 1.

230

CHRONIC MYELOPROLIFERATIVE NEOPLASMS

Pastore YD, Jelinek J, Ang S, Guan Y, Liu E, JedlickovaK, KrishnamurtiL, Prchal JT (2003): Mutations in the VHL gene in sporadic apparently congenital polycythemia. Blood 101~1591-1595. PeetersP, RaynaudSD, Cools J, WlodarskaI, GrosgeorgeJ, Philip P, MonpouxF, Van RompaeyL, BaensM, Van denBergheH, MarynenP (1997):Fusionof TEL,theETS-variantgene 6 (EW6),to the receptor-associated kinaseJAK2as a resultof t(9;12) in a lymphoidandt(9;15;12)in a myeloid leukemia.Blood 90:2535-2540. Popovici C, ZhangB, GregoireMJ, JonveauxP, Lafage-PochitaloffM, BimbaumD, PebusqueMJ ( 1999): The t(6;8)(q27;p11) translocationin a stem cell myeloproliferative disorderfuses a novel gene, FOP, to fibroblastgrowthfactorreceptor1. Blood 93: 138 1-1389. RaskindWH, JacobsonR, MurphyS, AdamsonJW,FialkowPJ ( 1985): Evidencefor the involvement of B lymphoid cells in polycythemia Vera and essential thrombocythemia.J Clin Znvest 75:1388-1390. Rege-CambrinG, MecucciC, TricotG, MichauxJL, LouwagieA, Van Hove W, FrancartH, Van den Berghe H ( 1 987): A chromosomalprofile of polycythemia Vera. Cancer Genet Cytogenet 25233-245. Rege-CambrinG, SpelemanF, Kerim S, ScaravaglioP, CarozziF, Dal Cin P, MichauxJL. OffnerF, Saglio G, Van den BergheH (199 1): Extratranslocation der(lq9p) is a prognosticindicatorin myeloproliferativedisorders.Leukemia5:1059-1063. Reilly JT, Snowden JA, Spearing RL, Fitzgerald PM, Jones N, Watmore A, Potter A (1997): Cytogeneticabnormalitiesand theirprognosticsignificancein idiopathicmyelofibrosis:a study of 106 cases. Br J Haematol98:96-102. ReiterA, Sohal J, KulkarniS, Chase A. MacdonaldDH, AguiarRC, Goncalves C, HernandezJM, Jennings BA, Goldman JM, Cross NC ( I 998): Consistent fusion of ZNF198 to the fibroblast growth factor receptor-] in the t(8;13)(pl 1 ;q 12) myeloproliferative syndrome. Blood 92:1735- 1742. ReiterA, WalzC, WatmoreA, SchochC, Blau I, SchlegelbergerB, BergerU, TelfordN, AruliahS, Yin JA, VanstraelenD, BarkerHF, Taylor PC, O’Driscoll A, Benedetti F, Rudolph C, Kolb HJ, Hochhaus A, Hehlmann R, Chase A, Cross NC (2005): The t(8;9)(p22;p24)is a recurrent abnormalityin chronicand acuteleukemiathatfuses PCMl to JAK2.CancerRes 652662-2667, Roche-LestienneC, AndrieuxJ (2007): Cytogeneticsand moleculargenetics in myelofibrosiswith myeloid metaplasiaand polycythemiaVera. PatholBiol55:49-55. RosatiR, La StarzaR, BardiA, LucianoL, MatteucciC, PieriniV (2006a):PDGFRBfusestoTPM3in the t(1;5)(q23;q33)of chronic eosinophilic leukemia and to NDEl in the t(5;16)(q33;p13)of chronicmyelomonocyticleukemia.Haematologica91(Suppl I): 214. RosatiR, La StarzaR, LucianoL, Gore110P, MatteucciC, PieriniV, Romoli S, CrescenziB, RotoliB, MartelliMF, Pane F, Mecucci C (2006b): TPM3PDGFRBfusion transcriptandits reciprocalin chroniceosinophilicleukemia.Leukemia20: 1623- 1624. Ross TS, BernardOA. BergerR, GillilandDG (1998): Fusion of Huntingtininteractingprotein1 to platelet-derivedgrowthfactorbeta receptor(PDGFbetaR)in chronicmyelomonocyticleukemia with t(5;7)(q33;qll.2). Blood 9 1 3 4 1 9 4 2 6 . RoulstonD, EspinosaR U1, Stoffel M, Bell GI, Le Beau MM (1993): Moleculargeneticsof myeloid leukemia: identification of the commonly deleted segment of chromosome 20. Blood 823424-3429. SchwallerJ, AnastasiadouE, Cain D, KutokJ, Wojiski S, Williams IR,La StarzaR, CrescenziB, SternbergDW, AndreassonP, SchiavoR, SienaS, Mecucci C, GillilandDG (200 I): H4(DiOSI70). a gene frequentlyrearrangedin papillarythyroidcarcinoma,is fused to the platelet-derivedgrowth factor receptorbeta gene in atypical chronic myeloid leukemia with t(5:1O)(q33;q22).Blood 97:391&3918.

+

REFERENCES

231

ScoreJ, CurtisC, WaghornK, StalderM, JotterandM, GrandFH,CrossNC (2006): Identificationof a novel imatinib responsive KIF5B-PDGFRA fusion gene following screening for PDGFRA overexpressionin patientswith hypereosinophilia.Leukemia20:827-832. ScottLM, Tong W, Levine RL, Scott MA, Beer PA, StrattonMR, FutrealPA, ErberWN, McMullin MF, HarrisonCN, Warren AJ, Gilliland DG, Lodish HE Green AR (2007): JAK2 exon 12 mutationsin polycythemiaVera and idiopathicerythrocytosis.N Engl J Med 356:459468. SessaregoM, DefferrariR, Dejana AM. RebuttatoAM, FugazzaG, Salvidio E, AjmarF (1989): Cytogeneticanalysisin essentialthrombocythemia at diagnosisand at transformation. A 12-year study. CancerGenet Cylogenet4357-65. ShannonKM,TurhanAG, RogersPC,Kan YW (1992):Evidenceimplicatingheterozygousdeletion of chromosome7 in the pathogenesisof familialleukemiaassociatedwithmonosomy7. Genomics 14:I2 1-1 25. SinclairEJ,ForrestEC, Reilly JT,WatmoreAE, PotterAM (200 1): Fluorescencein situ hybridization analysis of 25 cases of idiopathic myelofibrosis and two cases of secondary myelofibrosis: monoallelicloss of RBI, D13S319 and D13S25 loci associatedwith cytogeneticdeletion and translocationinvolving 13q14.Br J Haemafol I 13:365-368. SteensmaDP, Dewald GW, Lash0 TL,Powell HL, McClureRF, Levine RL, GillilandDG,TefferiA (2005): The JAK2 V617F activatingtyrosine kinase mutation is an infrequentevent in both “atypical”myeloproliferativedisordersand myelodysplasticsyndromes.Blood 106:1 207- 1209. SterkersY, PreudhommeC, Lai JL, Demory JL, CaulierMT, Wattel E, BordessouleD, BautersF, Fenaux P ( 1998): Acute myeloid leukemiaand myelodysplasticsyndromesfollowing essential thrombocythemiatreatedwith hydroxyurea:high proportionof cases with 17p deletion. Blood 9 1:616-622. StoverEH, Chen J, Folens C, Lee BH, MentensN, MarynenP, WilliamsIR, GillilandDG, Cools J (2006): Activationof FIP1L I-PDGFRalpharequiresdisruptionof thejuxtamembranedomainof PDGFRalphaand is FIPlL1-independent.Proc Natl Acad Sci USA 103:8078-8083. Swolin B, WeinfeldA, Westin J (1986):Trisomy Iq in polycythemiaVera and its relationto disease transition.Am J Hematol22:155-167. Swolin B, WeinfeldA, WestinJ (1988): A prospectivelong-termcytogeneticstudy in polycythemia Vera in relation to treatmentand clinical course. Blood 72:38&395. SwolinB, RodjerS, RoupeG (2000):Cytogeneticstudiesin patientswithmastocytosis.CancerGenet Cytogenet 120:131-135. Swolin B, RodjerS, OgardI, RoupeG (2002): Trisomies8 and 9 not detectedwith FISH in patients with mastocytosis.Am J Hematol70:324-325. Tefferi A, GillilandDG (2007): Oncogenesin myeloproliferativedisorders.Cell Cycle 6:550-566. Tefferi A, VardimanJW (2008): Classificationand diagnosisof myeloproliferativeneoplasms:the 2008 World Health Organizationcriteriaand point-of-care diagnostic algorithms.Leukemia 22: 14-22. TefferiA, Mesa RA, SchroederG, HansonCA, Li CY, Dewald GW (2001): Cytogeneticfindingsand theirclinical relevancein myelofibrosiswith myeloid metaplasia.Br J Haematol I 13:763-771. Teofili L, GionaF, MartiniM,CenciT, GuidiF, Torti L, PalumboG, AmendolaA, FoaR, LaroccaLM (2007): Markersof myeloproliferativediseases in childhood polycythemiaVera and essential thrombocythemia.J Clin OncoZ25:1048-1053. ThirdInternationalWorkshopon Chromosomesin Leukemia(1 981 ): Reporton essential thrombocythemia.CancerGenet Cylogenet4: 138-142. Tiedt R, Hao-Shen H, Sobas MA, Looser R, DirnhoferS , SchwallerJ, Skoda RC (2008): Ratio of mutantJAK2-V617Fto wild type JAK2 determinesthe MPDphenotypesin transgenicmice. Blood I 1 1:3931-3940.

232

CHRONIC MYELOPROLIFERATIVENEOPLASMS

Tothova E, FricovaM, Stecova N, Hlebaskova M. =ova A, Raffac S, Guman T, Svorcova E, Nebesnakova E (2001): Leukemic transformationof polycythemia Vera after treatmentwith hydroxyureawith abnormalitiesof chromosome17. Neopiasm 48:389-392. VandenbergheP, WlodarskaI, MichauxL, ZacheeP, BoogaertsM, VanstraelenD, HerregodsMC, Van Hoof A, Selleslag D, Roufosse F, MaerevoetM, Verhoef G, Cools J, GillilandDG, HagemeijerA, MarynenP (2004):Clinicalandmolecularfeaturesof FlPlL I -PDFGRA( + ) chroniceosinophilic leukemias.Leukemia 18:734-742. VannucchiA M , AntonioliE, GuglielmelliP,RambaldiA, BarosiG,MarchioliR, MarfisiRM, Finazzi G, GueriniV, FabrisF. Randi ML, De SV, CaberlonS,TafuriA, RuggeriM, SpecchiaG, Liso V, Rossi E, Pogliani E, GugliottaL, Bosi A, BarbuiT (2007): Clinicalprofileof homozygousJAK2 617V > F mutation in patients with polycythemia Vera or essential thrombocythemia.Blood 110:840-846. VardimanJW,HarrisNL, BrunningRD (2002):The WorldHealthOrganization(WHO)classification of the myeloid neoplasms.Blood 100:2292-2302. Vizmanos JL, Novo FJ, Roman JP, Baxter EJ, LahortigaI, LarrayozMJ, Odero MD, GiraldoP, CalasanzMJ,CrossNC (2004):NIN,a gene encodinga CEPl 10-likecentrosomalprotein,is fused to PDGFRB in a patientwith a t(5;14)(q33;q24)and an imatinib-responsivemyeloproliferative disorder.Cancer Res 64:2673-2676. WalzC, ChaseA, SchochC, WeisserA, SchlegelF, HochhausA, FuchsR. Schmitt-GraffA, Hehlmann R, CrossNC, ReiterA (2005): Thet(8;17)(pl l;q23) in the 8pl1 myeloproliferativesyndromefuses MYO18A to FGFRI. Leukemia 19:1005-1009. Walz C, CurtisC, SchnittgerS, SchultheisB. MetzgerothG, SchochC, LengfeiderE, ErbenP,Muller MC, HaferlachT, HochhausA. HehlmannR, Cross NC, ReiterA (2006): Transientresponseto imatinib in a chronic eosinophilic leukemia associated with ins(9;4)(q33;q12q25) and a CDK5RAP2-PDGFRA fusion gene. Genes Chromosomes Cancer 45:95&956. Walz C, MetzgerothG, HaferlachC, Schmitt-GraeffA, FabariusA, Hagen V, Prummer0, Rauh S, HehlmannR, HochhausA, Cross NC, ReiterA (2007): Characterization of threenew imatinibresponsive fusion genes in chronic myeloproliferativedisordersgeneratedby disruptionof the platelet-derivedgrowth factorreceptorbeta gene. Haematologica 92.163-169. Wang JC, Lang HD, LichterS, WeinsteinM, Benn P (1992): Cytogeneticstudiesof bone marrow fibroblastsculturedfrom patients with myelofibrosis and myeloid metaplasia.Br J Haemafol 80:I 8 4 1 88. WilkinsonK, Velloso ER, Lopes LF, Lee C, AsterJC, ShippMA, AguiarRC (2003): Cloningof the t ( 1;5)(q23;q33)in a myeloproliferativedisorderassociated with eosinophilia: involvementof PDGFRBand responseto imatinib.Blood I 0 2 4 I8741 90. Xu G, KanezakiR, Toki T, WatanabeS,TakahashiY,TeruiK,KitabayashiI, It0 E (2006): Physical association of the patient-specific GATAl mutantswith RUNXl in acute megakaryoblastic leukemiaaccompanyingDown syndrome.Leukemia 20: 1002-1 008. ZaccariaA, TuraS (1978): A chromosomalabnormalityin primarythrombocythemia.N EngZJ Med 298: 1422-1423. ZipurskyA (2003): Transientleukaemia:a benign formof leukaemiain newborninfantswith trisomy 21. Br J Haematol 12093CL938.

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CHAPTER9 ~~

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Acute Lymphoblastic Leukemia CHRISTINEJ. HARRISONand BERTILJOHANSSON

Acute lymphoblasticleukemia(ALL) is characterizedby the accumulationof malignant, immaturelymphoidcells in the bone marrowand, in most cases, also in peripheralblood. The disease is classified broadly as B- and T-lineage ALL. It is the most common malignancyin children,representingalmost 25% of pediatriccancer.The total incidence of ALL in childhoodis 3 4 per 100,000peryear,while for adultsit is less than 1. Thereis a peakin incidenceamongchildrenaged 2-5 years,whichis approximatelyfourtimesgreater than infants and almost 10 times greaterthan adolescents.For unexplainedreasons, the incidenceof ALL is almostthreetimeshigherin whitechildrenthan blackchildren.Among adults,ALL is more frequentin youngerpatients,with a medianage of less than30 years. Males are more often affected than females.

MORPHOLOGIC, IMMUNOPHENOTYPIC, AND CYTOGENETIC CHARACTERISTICS

B-Lineage ALL B-cell precursorALL (BCP-ALL)is a malignancyof lymphoblastscommittedto the B-cell lineage.The morphologyof thecells is largelyof theFAB L1 orL2 type (see below). A small BCP-ALLis primarilya disease percentageof patientshavea matureB immunophenotype. of childhood in that 75% of patients are under the age of 6 years. Bone marrow and peripheralblood are involved in all cases, with frequentextramedullaryinvolvement, primarilyof the centralnervoussystem (CNS), lymph nodes, spleen, liver, and testes (Pui et al., 2004). Cytogeneticsremainsthe “gold standard”techniquefor the genetic classificationof ALL, althoughmorerecentstudieshave proposedthe classificationof childhood BCP-ALL by gene expression profiling. Gene expression signatureshave been used to define the significantgenetic subgroups,to predictrelapse,and highlightnovel molecular targetsfor therapy(Yeoh et al., 2002; Ross et al., 2003).

Cancer Cytogenetics, Third Edition. edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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ACUTE LYMPHOBLASTIC LEUKEMIA

T-Lineage ALL T-lineageALL (T-ALL),which accountsfor approximately15%of childhoodand 25%of adultALL, is a high-riskmalignancyof thymocytes( h i et al., 2004). It is a heterogeneous disease classified accordingto the expressionof specific cytoplasmicor surfacemarkers (Bene et al., 1995). The developmentof normalthymocytesand theirregulationmechanisms havebeen studiedextensively,andit has been shownthatthe significantgenes in T-cell developmentare also rearrangedor deregulatedin T-ALL (Grauxet al., 2006). This is supportedby the gene expressionsignaturesof T-ALL,which mirrorthe specific stagesof thymocyte development (Ferrandoand Look, 2003). Collectively, these observations indicate a multistep process of pathogenesis in T-ALL (Graux et al., 2006), further supportedby the simultaneousOccurrenceof multiple genetic changes in the leukemic cells (Harrison,2007).

Morphologic and lmmunophenotypic Features ALL may be subdividedinto subgroupson the basis of cytomorphologicfeatures.The French-American-British(FAB) classification(Bennettet al., 1976) constitutedthe most widely acceptedscheme. Althoughrarelyused in recentyears,it has providedthe basis for the developmentof currentclassificationsystems.The FAB system takesinto accountboth the characteristicmorphologyof individualcells andthe degreeof heterogeneitywithinthe leukemiccell population.The salientfeaturesof thethreeALL subgroupsrecognizedby the FAB classificationare the following. L1: Smallcells with homogeneousnuclearchromatin, regularnuclear shape, and indistinctnucleoli. This category includes the majority of childhoodcases, whichmay be of B- orT-cell lineage.L2: Largercells of morevariablesize and distributionof nuclearchromatinthan in L1. The nuclearshapeis more irregular,and one or more large nucleoli may be present.Approximately25% of ALL cases are in this category,andthey may be of B- as well as of T-cell lineage. L3: Large,homogeneouscells with finely stippled nuclear chromatin,regularnucleus, prominentnucleoli, and often prominentvacuolationof the basophiliccytoplasm.This categorycomprisesonly 1-2% of ALL. There is little associationbetween these cytological featuresand the immunophenotype,apartfroma strongcorrelationbetweenL3 anda matureB immunophenotype. This is consideredas the leukemicequivalentof Burkittlymphomaandis regardedas a distinct disease entity. Increasedemphasis on the functionalaspects of cellular maturationand differentiation led to the proposalof additionalclassificationcriteriafor ALL (FirstMICCooperative Study Group, 1986). The MIC classification(Morphology-Immunology-Cytogenetics) was a first attemptto combine informationobtainedfrom these three fields of leukemia researchinto a diagnosticscheme that reflected the intrinsicpathobiologyof the various ALL subtypes. Leukemic cells of different types express characteristicnuclear, cytoplasmic,andcell surfaceantigens,whichcan be identifiedwith monoclonalantibodies.This is termed the immunophenotype.There are several hundredmonoclonal antibodiesthat allow the detection of more than 260 clusters of differentiation (CD)groupings.The MIC system defines four majorimmunologicsubclassesof B-lineage ALL: (1) In early B-precursor ALL (or earlypre-B ALL, sometimesknown as pro-B),the immunophenotype and the beginning of immunoglobulinlocus rearrangementsstrongly indicate that the cells are committed to B-lineage differentiation.They always express CDl9, human leucocyte antigen (HLA)-DR, terminal deoxynucleotidyl transferase(TdT), and the

MOST PATIENTSWITHALLHAVECHARACTERISTIC,ACQUIRED KARYOTYPICABNORMALITIES

235

majority express CD22 and CD79a. This leukemia-type accounts for approximately 10%of adultand childhoodALL. (2) When the leukemiccells expressthe common ALL antigen (CDIO) in addition to CD19 and TdT, this is consideredto be a sign of further maturation.The leukemia is then classified as common ALL, the most frequentALL subtype,accountingfor about 60%of childhood and adult ALL. (3) As the cells start to expressimmunoglobulinin the cytoplasmas well as CD79b, the leukemiais termedpreB-ALL. The expressionof the other markersis identicalto common ALL. This subtype accountsfor 20-25% of childhoodALL. Thesethree subtypestogether+xdy B-precursor ALL, common ALL, and pre B-ALL-comprisethe BCP-ALL category. (4) The most mature acute leukemia of the B-lineage, mature B-cell ALL, is diagnosed when the leukemiccells expressimmunoglobulinswith single light-chainson the cell surface.These leukemiccells invariablyhave L3 morphologyand are consideredas the leukemicequivalent of Burkitt lymphoma.They account for approximately5%of adult and 2% of childhoodALL. Only two immunologicalcategoriesof T-lineageALL are defined by the MIC classification:(1) early T-precursor ALL and (2) the morematureT-ALL.All blastsexpresssurface CD7 andcytoplasmicCD3, with variableexpressionof TdT,CD34, CD2, andCD5. HLADR expression in T-ALL is characteristicof an immatureclone. T-cell ALL can be subdivided accordingto the stages of T-cell developmentinto pro-T, pre-T, cortical-T, and mature-T. The MIC subgroupsare associated with nonrandomkaryotypicabnormalitiesin a mannercomparableto the specificity seen between chromosomalrearrangementsand morphologicsubgroupsin acute myeloid leukemia(AML;Chapter5). More recently,the World Health Organisation(WHO) developed a more advanced classification defining precursor B lymphoblastic leukemia and precursor T-lymphoblastic leukemia (Brunning et al., 200 I). This systemincorporatescytomorphology,immunophenotype, andgeneticsto define the categoriesof these two subgroups.

MOST PATIENTS WITH ALL HAVE CHARACTERISTIC, ACQUIRED KARYOTYPIC ABNORMALITIES IN THEIR LEUKEMIC CELLS An early cytogenetic review undertaken by the Third InternationalWorkshop on Chromosomes in Leukemia (JWCL3, 1982) found clonal chromosomal aberrations in 66%of the 330 patients (173 adults, 157 children) investigated. Higher aberration frequencies, up to almost 90%, have been reported more recently (Groupe Francais de CytogenetiqueHematologique,1993; Harrisonet a]., 2005; Moormanet al., 2007a). These revised incidences have included the detection by fluorescence in situ hybridization (FISH) of cryptic abnormalitiesand those hidden within cases with a failed cytogenetic result. There are now numerous nonrandom chromosomal rearrangementsknown with clinical significance in relation to diagnosis and prognosis. Many are also of special interestbecauseof the insightsthey haveprovidedinto the molecularmechanismsof ALL pathogenesis.The abnormalitiesmay be numericalor structural,with many karyotypes containing both types of change. New abnormalitiesare added every year, not least because state-of-the-arttechnologies are increasingly being introducedinto leukemia diagnostics.Throughoutthe 1980s and 1990s advancingtechniquesin FISH,particularly around the Human Genome mapping project (McPherson et al., 2001), led to the

236

ACUTE LYMPHOBIASTIC LEUKEMIA

development of probes for any known human DNA sequence. More recently, studies utilizing array-basedcomparativegenomic hybridization(aCGH)and single-nucleotide polymorphism(SNP) arrays have revealed novel chromosomalchanges, many below the resolution of chromosome banding analysis, which have greatly enhanced the understandingof the genetic mechanisms involved in leukemogenesis (Mullighan et al., 2007). It is now the conventionto include these methodologies as complementary cytogenetic techniques, which has brought cytogenetic analysis fashionablyback into the 21st century. Differenttypes of chromosomalrearrangementsare predominantin BCP-, matureB, and T-ALL. Numericalchanges affectingploidy arecharacteristicof BCP-ALL,as are translocationsthatproducefusion genes. These areformedby “in-frame”fusion of parts of thetwo partnergenes locatedat the chromosomalbreakpoints.The fusiongene encodes a new chimericproteinwith oncogenic potential(Harrisonand Foroni,2002). Thesetypes of translocationsareless frequentin T-ALL,which insteadoften harbortranslocationsor inversions involving the T-cell receptor (TCR) loci; a (TRA)and 6 (TRD)located in chromosomal band 14ql1, and p (TRB) and y (TRG) located in 7q34 and 7p14, respectively. Such abnormalitiesare found in approximately35% of T-ALL by FISH (Cauwelier et al., 2006), with many being cryptic at the cytogenetic level. These chromosomalrearrangementsresult in oncogenes becoming juxtaposedto the promoter and enhancer elements of the TCR genes, leading to their aberrantexpression (Rabbitts, 1994). Alternatively,aberrantexpression of oncogenic transcriptionfactors in T-ALL may resultfromloss of the upstreamtranscriptionalmechanismsthatnormally downregulatethe expression of these oncogenes during T-cell development (Ferrando et al., 2004a; van Vlierbergheet a].. 2006). This mechanism of oncogene upregulation predominatesin mature B-ALL, in which the promotersof the immunoglobulinloci upregulateMYC as a result of the t(8;14)(q24;q32) and its varianttranslocations(see below and Chapterlo). The cytogenetic,moleculargenetic, and clinical featuresof ALL-associatednumerical andstructural chromosomeabnormalities reportedin a sufficientnumberto allowdelineation of clinico-geneticassociationsaresummarizedbelow as well as in Table9.1.

ESTABLISHED PLOIDY GROUPS IN ALL Ploidy groups representing significant and established cytogenetic entities in ALL comprise high hyperdiploidy ( 5 1-65 chromosomes), near-haploidy(25-29 chromosomes), low hypodiploidy(31-39 chromosomes),near-triploidy(66-79 chromosomes), and near-tetraploidy(84-100 chromosomes).Low hyperdipioidy(47-49 chromosomes) or hypodiploidywith45 chromosomes,as well as single numericalaberrations(apartfrom possibly trisomy 5 ) , is, as a result of novel technologies, increasingly being found as secondarychanges associated with specific structuralabnormalities,which will be discussed in the relevantsections below.

High Hyperdiploidy High hyperdiploidy(Fig. 9. I), the most common cytogenetic subgroupin BCP-ALL,is defined as the presence of 51-65 chromosomes with the most frequentmodal chromosome numberbeing 55 (Pui et al., 1989; Moormanet al., 2003; Heeremaet al., 2007).

4

W

h)

MLL-EPSI 5

t( 1 ;11)(p32;q23)

STIL-TALI

B4GALT3, DAP3, RGSI6, TMEMl83A. and LICK2 overexpression TCF3-PBXI IGK-MYC MLL-AFFI

BCLl IB-TLX3

del(l)(p33p33)

t( 1;19)(q23;p13.3) t(2;8)(p1 1;q24) t(4;l l)(q21;q23)

t(5;14)(q35;q31)

High hypodiploidy

Low hypodiploidy

TRA/D-TALI

Whole chromosomegains, FLT3, NRAS, KRAS, PTPN11, and PAX5 mutations Whole chromosomegains onto the haploid set Whole chromosome gains onto the haploid set Chromosomeloss and structuralchanges unknown TRB-LCK TRB-TALI

High hyperdiploidy

Near-haploidy

Genetic Features

Aberration

All All Mainly infants, some children and adults All

+

Pre-B, CDlO + , cIg + MatureB-ALL Early pre-B, CD10-, CD19 T-ALL

B-lineage

T-ALL

T-ALL

Poor

Standard Favorable Poor

Unknown

(continued)

Better than other T-ALL

Better than other T-ALL

Variable

Poor Unknown Better than other T-ALL

Pre-B T-ALL T-ALL

Older children Older children and adults Mostly children, some adults Mainly infants, some childrenand adults Mostly children, some adults Mostly children, some adults All

Commodpre-B

Poor (if <44 chromosomes)

Poor

Poor

Favorable

Risk

B- and T-lineage

Commodpre-B

Commodpre-B

Commodearly _pre-B, . CDlOf

lmmunophenotypic Features

All

Adults

Children

Mostly children, some adults

Age Group

TABLE 9.1 Cytogenetic, Molecular Genetic, and Clinical Features of ALL-Associated Chromosomal Aberrations

u

t(6;7)(q23;q34) MYB duplication t(6;I l)(q27;q23) t(6;14)(p22;q32) inv(7)(p15q34) t(7;7)(p15;q34) t(7;14)(p15;ql1) t(7;14)(p15:q32) diC(7;9)(p11-13;~11- 13) i(7)(q10) t(7:9Mq34q32) t(7;9)(q34;q34.3) NOTCHI mutations t(7;lO)(q34;q24) t(7;l l)(q34;pt3) t(7;1l)(q34;p15) t(7;12Xq34pl3.3) t(7;12)(q36;p13) t(7;I9)(q34;p13) t(8;14)(ql l;q32) t(8;14)(q24;qll) t(8;14)(q24;q32) t(8;22)(q24;qlI) del(9p) t(9;12)(p24;pl3) di~(9;12)(pll-12;~11-13)

Aberration

TABLE 9.1 (Continued)

All Young children Young children All Olderchildrenand adults All All All All All All All All

Unknown

TRB-MYB MYB overexpression MLL-MLLT4 IGH-ID4 TRB-HOXQ TRB-HOXA TRD-HOXA BCLI 1B-HOAX PAX5 deletion(?) Unknown TRB-TAU TRB-NOTCHI NOTCHI activation TRB-TLXI TRB-LMOI TRB-LMO2 TRB-CCND2 ETV6-MNXl TRB-LYLl IGH-CEBPD TCRA/D-MYC IGH-MYC IGL-MYC CDKN2A deletion ETV6-JAK2 ETV6-PAX5 All All One child All

A11

All All Children Children All Infants All Olderchildrenand adults All

Age Group

Genetic Features Mostly commodpre-B, some T T-ALL T-ALL B- and T-lineageALL Pre-B T-ALL T-ALL T-ALL T-ALL B-lineage he-8 T-ALL T-ALL T-ALL T-ALL, early cortical T-ALL T-ALL T-ALL Commodpre-B T-ALL Pre-B T-ALL MatureB-ALL MatureB-ALL B- and T-lineage T-ALL he-B

Immunophenotypic Features

Unknown Unknown Poor Unknown Unknown Unknown Unknown Unknown Variable Unknown Unknown Unknown Poor BetterthanotherT-ALL Unknown Unknown Unknown Poor Poor Unknown Unknown Favorable Favorable Variable Unknown Favorable

Standard[OK?]

bsk

PICALM-MLLTIO MLL-MLLTI 0 TRA/D-TLXI

TRA/D-LMOI TRA/D-LMOZ MLL-MLLT1

TRA-CCND2 TAFl.5-ZNF384

TCF3-ZNF384 andNOLITCF3 EW6-R UNXl

EWSRl -ZNF384

Unknown TRA-TCLI TRD-BCL11B

i(9)(q10) t(9;9)(q34;q34) t(9;IO)(q34;q22.3) t(9;1 l)(p2 1 ;q23) t(9;14)(q34;q32) t(9;22)(q34;qlI)

t(10;1l)(p12;q14) 10p12/1lq23 rear. t(10;14)(q24;ql1)

t( 1 1;14)(p13;ql1) t(11;14)(p15;qlI ) t( 1 1;19)(q23;p13.3)

t( 12;14)(p13;qil) t(12;17)(p13;qll)

t( 12;19)(p13;p13)

t(l2;22)(p13;q12)

del(13)(q12- 14) inv(14)(qllq32) inv(l4)(qlIq32)

t( 12;21)(p13;q22)

CDKN2A and PAX5 deletion (?) Unknown NUP2 14-ABLI ZMIZl -ABLl MLL-MLLT3 EMLl -ABLI BCR-ABLI

Childrenand adults All All

Young adults

Young children

+ +

+

+, Pre-B, CD13 , CD33 CDw65 Early pre-B, CD 13 , CD30 B-lineage T-ALL secondaryto AT T-ALL

+

Unknown Unknown Unknown

Unknown

Favorable

(continued)

Unknown Unknown

T-ALL Earlypre-B, CDl3 CD30 Variantt( 1;19)

Unknown

unknown Unknown Poor

T-ALL T-ALL Pre-B

+

Poor Poor Betterthan otherT-ALL

T-ALL Pre-B and TALL T-ALL, early cortical

All

Unknown Unknown Unknown Unknown Unknown Extremelypoor

Mostly pre-B T-ALL Pre-B Pre-B T-ALL Pre-B

Olderchildrenand adults Adults Adults All All Mainly adults,some children Childrenand adults All Mainly adults,some children Childrenand adults Childrenand adults Mainly infants,some childrenand adults Children Young adults

+,

Standardpoor

Pre-B

Young children

Age Group Olderchildrenand adults All All Olderchildrenand adults Adults Olderchildrenand adults Olderchildrenand adults All Mainly infants,some children All All A11 Olderchildren

Genetic Features

IGH-CEBPE TRA-TCLl TRD-BCLI 1 B IGH-CEBPE IGH-BCL2 IGH- CEBPA IGH-CEBPB TRA-OLIG2 Unknown

Unknown TCF3-HLF Unknown RUNXI amplification(?)

Aberration

inv(l4)(ql lq32) t( 14;14)(ql1;q32) t(14;14)(qll;q32) t(14;14)(qIl;q32) t(14;18)(q32;q21) t(1419)(q32;q13) t(14;20)(q32;ql3) t(14;21)(qIl;q22) 15q13-15 rear.

i(17Xq10) t(l7;19)(q22;p13) i(21)(q10) iAMP21

TABLE 9.1 (Continued)

B- and T-lineage Pre-B Pre-B Commodpre-B

Pre-B TALL secondaryto AT T-ALL Pre-B Pre-B and matureB Pre-B Pre-B T-ALL B-lineage

Features

lmmunophenotypic

Unknown Extremelypoor Unknown Extremelypoor

Unknown Unknown Unknown Unknown Poor Unknown Unknown Unknown Standard

Risk

ESTABLISHED PLOIDY GROUPS IN ALL

241

The gain of chromosomesis nonrandomand eight chromosomesaccountfor close to 80%of all gains: + 4 (78% of cases), $ 6 (85%). 10 (63%), 14 (84%), + 17 (68%). 18 (76%), $21 (99%),and +X (89%).The gains usually presentas trisomies (or two copies of the X chromosomein males). The exceptions are of chromosome21, which is tetrasomicin approximately70%of cases, and tetrasomiesof chromosomes 14 and 18, which occur in less than 5% of cases. Structuralchromosomal abnormalitiesare also presentin around50% of cases. Abnormalitiesof the long arm of chromosome 1 (lq), usually representing a partial duplication, are the most frequent, being present in approximately15% of cases (Davidsson et al., 2007). Deletions of 6q are seen in 7% andareusually independentof Iq abnormalities.Isochromosomesoccur in about4%, the mostfrequentis i( 17)(qlo), which is presentin 2%(Moormanet al., 2003). Mutationsand deletionsof the PAX5 gene arecommon in childhoodhigh-hyperdiploidALL (Mullighan et al., 2007). Mutationsof the FLT3, NRAS, KRAS,andP T P N l l have also been found in approximatelyone-thirdof cases, where they appearto be mutuallyexclusive (Paulsson et al., 2008). Thereis strongevidence thatsome childhoodleukemiasarise in utero, includingthose with high hyperdiploidy(Greaves,2005). The supportcomes from the findingof the same leukemia-relatedabnormditiesand clonogenic immunoglobulingene rearrangementsin neonatalblood spots and cordblood priorto the developmentof overt leukemia.With this

+

+

1

2

6

7

13

19

14

20

+

3

5

4

8

9

10

15

21

16

22

11

17

X

12

18

Y

FIGURE 9.1 Karyogrm showing a high-hyperdiploid karyotype from a childhood ALL patient: 55,XY,+X,+4,+5,+6,+10,+14,+17,+21,+21.

242

ACUTE LYMPHOBLASTIC LEUKEMIA

in mind, it is also of interest to consider how high hyperdiploidy is acquired.Four possibilities can be envisaged: (I) by initial near-haploidyfollowed by doubling of the chromosomes,(2) the developmentof tetraploidyfollowed by losses, (3) sequential gainsof chromosomesin consecutivecell divisions,or(4) the simultaneousgainof multiple chromosomesin a single abnormaldivision (Onoderaet al., 1992). Mechanism 1 occurs, albeitrarely,specificallyin associationwith near-haploidy(see below). Otherwise,thereis compelling molecular evidence to indicate that most cases of high hyperdiploidyarise througha simultaneousgain of chromosomesin a single cell division (Onoderaet al., 1992; Paulssonet al., 2005b). High-hyperdiploidALL usually have a CD 10 positive, early pre-Bkommonimmunophenotype. The incidence differs significantlybetween childrenand adults. It has been reportedto be as high as one-thirdin childhood series, especially when FISH data are included (Harrisonet al., 2005), whereas among adults it is found in less than 10% (Moormanet al., 2007a). It was shown by FISHusing selected centromericprobesthatthe incidence of high hyperdiploidywas surprisinglyhigh in cases with a failed or normal cytogeneticresult (Harrisonet al., 2005). This emphasizesthe need to searchfor hidden high-hyperdiploidclones in such cases. Childrenwith high-hyperdiploid ALL respondwell to standardchemotherapyregimens. They consistently show a superioroutcome, along with patients with the translocation t( 12;21)(pl3;q22), when comparedto patients in other cytogenetic subgroups.Recent studieshave reportedevent-freesurvivalrates of greaterthan 80% at 5 years (Moorman et al., 2003; Forestieret al., 2008b). The best prognosisis found in youngerchildren(aged 1-9 years) comparedto older ones (aged 10-16 years), as well as in those with a higher modal chromosomenumber(56-67 versus 5 1-55 chromosomes)(Raimondiet al., 1996; Moormanet al., 2003). The good prognosis associated with the gain of specific chromosomes providesthe most likely explanationfor the improvedoutcome among the 56-67 chromosomegroup.Three earlypublicationsand two more recent ones have shown that gainsof chromosomes4, 10(Harriset al., I992), and 17 (Heeremaet al., 2000b) (referredto as tripletrisomies),as well as of chromosome18 (Moormanet al., 2003), conferimproved survivalon these patients.Initially triple (trisomies4, 10, and 17) and currentlydouble trisomies(chromosomes4 and 10) areused to classify patientswith high-hyperdiploidALL in the US treatmenttrials. The previous suggestion that the presence of structural abnormalitiespredictsrelapse (Pui et al., 1989) was not confirmedby two subsequent studies (Raimondiet al., 1996; Moormanet al.. 2003). It is thereforeconsideredunlikely that structuralabnormalitiesare of prognosticimportancein high-hyperdiploidALL.

Hypodiploid and Near-Haploid ALL Hypodiploidy,definedas less than46 chromosomes,is rarein ALL. It occursat an overall incidence of approximately5%, independentlyof age (Harrisonet al., 2004). Based on chromosomenumberandcharacteristiccytogeneticfeatures,hypodiploidcases clusterinto three distinct subgroups:near-haploidy(25-29 chromosomes),low hypodiploidy(3&39 chromosomes), andhigh hypodiploidy (40-45 chromosomes). The majority (80%) of hypodiploidcases have 45 chromosomes, showing that only a small numberexist with <45 chromosomes.Survivalanalysiscarriedout on a cohortof childrenwith ALL treated accordingto the Children’sCancerGroup(CCG)intensiveprotocolsconcludedthatpatients with hypodiploidyhad a progressivelyworseoutcomewith decreasingchromosomenumber

ESTABLISHED PLOIDY GROUPS IN ALL

243

(Heeremaet al., 1999a),thusraisingthe possibilitythatsubsetsof hypodiploidpatientshave differenttreatmentoutcomes.

Near-Haploidy (25-29 Chromosomes) Near-haploidyhas been identifiedas a rareand uniquepatientgroup(Gibbonset al., 1991; Raimondiet al., 2003; Harrisonet al., 2004). Althoughthe rangein chromosomenumberis 25-29, the majorityof cases have 26 chromosomeswith commonchromosomaldisomies (Fig.9.2). The mostfrequentadditionsto thehaploidchromosomeset areof chromosome2 I in all cases, followed by chromosomesX, Y, 14, and 18. This reflectsthe same patternof chromosomalgainsas seen in high-hyperdiploidALL (see above).Structuralabnormalities are rarewithin this group.A coincidentpopulationof hyperdiploidcells with double the chromosomenumber,representinga duplicationof the near-haploidcell line, is frequently present. Cytogenetic evidence has indicated that endoreduplicationis the mechanism responsible for this related population ( h i et al., 1990; Gibbons et al., 1991; Ma et al., 1998).The distinctivecytogeneticprofileof this doubledpopulation,with tetrasomies of most of thegainedchromosomes,distinguishesthesecases fromthosewith classicalhigh hyperdiploidy.This distinction is extremely important,given the opposing prognostic significancebetweenthesetwo patientgroups(see below) forwhichtreatmentdecisionsare based on the karyotype.

2

1

4

3

5

I 7

6

8

9

11

10

12

I

13

14

16

15

17

18

X

Y

8 19

20

21

22

FIGURE 9.2 Karyogram showing a near-haploid karyotype from a childhood ALL patient: 25,Y,+X,+21.

244

ACUTE LYMPHOBLASTIC LEUKEMIA

Low Hypodiploidy (31-39 Chromosomes) Reportsof ALL with low hypodiploidyof 3 1-39 chromosomesarealso rare.The original evidencethatthis groupdemonstratedconsistentnumericalchromosomalchangesdistinct from near-haploidycame from a small study of seven patients described as “severe hypodiploidy”(Callen et al., 1989). They show a numberof chromosomalgains onto the haploidchromosomeset in commonwith near-haploidpatients,namelyof chromosomesX, Y, 14, 18, and 21, but with additionalgains specific to them: most frequentlyof chromosomes 1, 11, and 19; followed by chromosomes5, 6, 8, 10, and 22; and less frequentlyof chromosomes2 and 12, while two copies of chromosomes3,4, 13, 15, and 16 are rarely seen. Apartfromtwo cases in whichthey were disomic(Charrinet al., 2004),chromosomes 7 and 17 are usually monosomic.Structuralchromosomalabnormalitiesaremorefrequent thanin the near-haploidgroup(Pui et al., 1990;Harrisonet al., 2004), but in common with the near-haploidgroup,the majorityof cases show cytogenetic evidence of a population with duplicationof the hypodiploid chromosome number, described as near-triploidy (Charrinet al., 2004).

Hidden Hypodiploid Clones Associated with Hyperdiploidy or Near-Triploidy Hyperdiploidyor near-triploidy,manifestingwith a doublingof gainedchromosomes,is likely to be masking a hidden near-haploid or low-hypodiploid clone. FISH with informativecentromericprobes and measurementof DNA index have provideduseful approaches when the presence of a hidden near-haploidflow-hyperdiploidclone is suspected (Starket al., 2001). It is recommendedthat these tests should be performed in such cases.

High Hypodiploidy (42-45 Chromosomes) Some studies have segregated patients with 42-44 chromosomes from those with 45, although their chromosomalchanges are similar. Their karyotypesdiffer significantly from the two groups with <40 chromosomes.They have a high incidence of complex chromosomalabnormalities,with preferentialinvolvementof chromosomes7,9, and 12 (Pui et al., 1990; Heeremaet al.. 1999a). The overall reductionin chromosomenumber may be attributableeither to whole chromosome loss or to unbalancedtranslocations resultingin dicentricchromosomes.The most frequentwhole chromosomelosses are of chromosomesX, Y,7, 9, and 13. Chromosome9 is the one most often involved in the formation of dicentrics, among which the tlic(9;20)(pl3;qlI) is the most common rearrangement(see below). Chromosomes 7 and 12 are the next most frequently involved. The most commonly observeddeletions are of the shortarmsof chromosomes 7, 9, and 12. Cell populations with duplication of the high-hypodiploidchromosome numberare not seen.

Clinical Features of the Different Hypodiploid Groups Patients with near-haploid and low-hypodiploid ALL have commordpre-B immune phenotypes,with the majorityhaving a low white blood cell (WBC) count (<50 x 109/L,).

ESTABLISHED PLOIDY GROUPS IN ALL

245

However, the two groupsshow differentage distributions.Near-haploidyis restrictedto childhood patients (Gibbons et al., 1991; Harrisonet al., 2004), with a median age of 7 years (range 2-15 years), while patients with low hypodiploidy include adults and children 2 9 years old. Althoughthe majorityis clusteredbetween 9 and 20 years of age, patientsup to the age of 73 years have been described.A particularlypoor outcome has been reported for children with near-haploidALL (Gibbons et al., 1991; Chessells et al., 1997; Harrisonet al., 2004). Patients with 31-39 chromosomeshave a similarly poor outcome (Pui et al., 1990; Heeremaet al., 1999a; Raimondiet al., 2003; Chamn et al., 2004), which is unchangedby the presenceof a duplicatedhyperdiploidpopulation. These observationsemphasizethe need for accuratediagnosis of near-haploidyand low hyperdiploidyto ensure that all cases with <40 chromosomes are classified into the appropriatehigh-risk groupfor treatment. Patients withhigh-hypodiploidALL are clinically as well as cytogenetically distinct from the near-haploidand low-hypodiploidgroups.The age range is 1-52 years with a similarincidence across all ages. The group includes patientswith T-ALLin additionto those with pre-Bkommonimmunophenotypes.Patientswith ALL with 4 2 4 5 chromosomes fare better overall than do the other hypodiploid groups, with no obvious association between the type of chromosomal abnormalityand outcome (Heerema et al., 1999a). Although Nachmanet al. (2007) indicatea poor outcome for all patients with less than 44 chromosomes, the numbers in their series are small. In terms of understandingthe prognosis among high-hypodiploidpatients, those known to have establishedchromosomalabnormalitiesshouldbe excluded.Forexample,it is commonto find ALL cases with EW6-RUhXI and BCR-ABLl fusions having 44 or 45 chromosomes, due to specifically associated chromosomal losses (Heerema et al., 1999a; Raynaudet al., 1999; Nachmanet al., 2007). Once excluded, the variableoutcome within the 42-45 chromosome group translates into an overall standard risk. Additional contributingfactors,maybe at the genetic level, need to be soughtto accuratelyclassify this heterogeneousgroup in terms of outcome.

Near-Triploidy Evidenceindicatesthat patientsreportedto have near-triploidyshould be includedwithin the low-hyperdiploidgroup (Charrinet al., 2004). They would be expected to harbora hidden low-hyperdiploidclone, which would be revealed by FISH with selected centromeric probesor by the measurementof DNA index.

Near-Tetrapiof dy Near-tetraploidy(84-1 00 chromosomes) has been reported in approximately 1% of childhood BCP-ALL and has been occasionally found also in T-ALL (Attarbaschi et al., 2006). It is currently unclear whether this ploidy group constitutes a defined cytogenetic entity. It was shown by Raynaudet al. (1999) that approximately6% of patients with the cryptic t( 12;21)(p13;q22) have a near-tetraploidkaryotype, while Attarbaschiet al. (2006) showed that 90% of BCP-ALL patients with near-tetraploidy harboredthe E T V 6 R U N X I fusion. Thus, they concluded that near-tetraploidywas a specific featureof E W 6 - R U N X I positive BCP-ALL,associatedwith the same excellent outcome affordedto other patientswith t(12;21).

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Trisomy 5 Although fewer than 20 cases have been reportedwith trisomy 5 as a sole cytogenetic abnormality,ALL with + 5 is emergingas a specific entity. They have a pre-B immunophenotypeand show a male predominance.This trisomyoccurs mostly in older children and, althoughnumbersare small, it appearsto be associatedwith a poor outcome (Harris et al., 2004).

STRUCTURAL REARRANGEMENTS The cytogenetic, moleculargenetic, and clinical featuresof ALL-associatedstructural abnormalitiesare summarizedbelow as well as in Table 9.1 in order of chromosome number.Aberrationsinvolving the same chromosomeare listed frompterto qter.Foreach anomaly, the Mitelman Database of Chromosome Aberrations in Cancer (Mitelman et al., 2008) has been searchedto identify the numberof cases reported,age, and the distributionof thepredominantmorphologicsubtypes.Forthe sakeof brevity,this database is not referredto herenor arethe referencesdetailedwithin as they can be easily resourced fromthe Web site. Throughout,we have focusedon the cytogeneticfeaturesandthe clinical implicationsof the various abnormalities.

W;7)(p34;q34) The LCK (lymphocyte-specificprotein tyrosine kinase) gene in lp34 is specifically expressed in T-cells and is overexpressedin rare cases of T-ALL as a result of t(1;7) (p34;q34),whichapposesLCKto the TRB locus at 7q34 (Bumettet al., 1994). As only three cases of T-ALL with this translocationhave been reported to date, no clear clinical associationshave emerged.

t(1;7)(p32;q34) The single reportedcase oft(1;7)(p32;q34)representsa rarevariantof the t( 1 ;14)(p32;qlI) in which TRB rather than TRA/D upregulatesTALl (T-cell lymphocyte leukemia 1, previouslyknown as TCL.5 or SCL) in T-ALL (see below) (Spelemanet al., 2005).

t(l;ll)(p32;q23) This reciprocaltranslocationhas been reportedin roughly 15 ALL, in the majorityas the sole karyotypicanomaly.It fuses the MLL (myeloidlymphoidor mixed-lineage leukemia) gene at 1 lq23 with EPSZS (epidermalgrowthfactorreceptorpathwaysubstrate15, previously known as MLLT.5 and AF-lp). This translocatiodgenefusion also occurs, albeit rarely,in AML (Chapter5). In ALL, the t( 1;I 1) has been reportedin patientsof all ages andequally often in males andfemales. The immunophenotypesarecommodpre-B ALL. The specific prognosticassociationof the t( I ;11) is unknowndue to its rarity.The fourALLcases reportedby Harrisonet al. ( 1998)werevariableforbothage andoutcome. For more details on MLL translocationsin ALL, see the section on t(4;l l)(q21;q23) below.

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t(1;14)(p32;q11)/ TAL7 Deletion In T-ALL,t(1;14)(p32;qll)juxtaposes the TALI gene at lp32 to TRA/D at 14qll (Brown et al., 1990; Carroll et al., 1990; Janssen et al., 1993) leading to deregulatedTALZ expression, similarly to the t( 1;7)(p32;q34) (see above). However, the most frequent rearrangement, in 16%of T-ALL, leading to overexpressionof TALI is a submicroscopic interstitialdeletion of part of lp32. It involves STIL (SCUTALZ interruptinglocus, previouslyknown as SIL or SCL), which lies centromericof TALI, and the 5’ untranslated region (UTR)of TALl generatinga STIL-TALl fusion gene. A second interstitiallp32 deletionhasbeen observedin about6%of T-ALL(Bernardet al., 1991). It involves another site within the TAW locus but the same region within STIL. TALI and STIL are both normallyexpressedin T-cell developmentandhigh expressionlevels of TALl in the absence of detectablerearrangements have been describedin approximately40%of T-ALL (Bash et al., 1995; Ferrandoet al., 2004a). These abnormalitiesleading to high TALI expression arecommonin childhoodT-ALL.They arefoundin 17%of such cases and are associated with a favorableoutcome (Cave et al., 2004).

dUp(1)(ql2-21q31-32) Althoughthis duplicationhas now been reportedin morethan 170 cases of ALL, it is only rarelyfound as the sole anomaly.It is thereforemostly a secondaryratherthan a primary aberration.The dup(I q) may resultfroman unbalancedtranslocationgiving rise to a der(l)t (l;l)(p?;q?).In aboutone-thirdof cases with dup(lq),the primaryrearrangement is t(8;14) (q24;q32)(seebelow). It has been reportedin approximately25%of Burkittlymphomas.In anotherthird, it is found in high-hyperdiploidkaryotypes,often as the only structural abnormalityamong the many numericalchanges. The evolutionarynature of dup(1q) becameevidentfromthe observationthatit appearedonly in relapse(Heeremaet al., 1992). The molecular genetic consequences are unknown, although a number of cases were investigatedby high-resolutionarrayCGH.This revealedthatthe proximalbreakpointsin all cases were near-centromeric, clusteringwithin a 1.4 Mb segmentin 1q 12-2 1.1. The 1q distalbreakpointswereheterogeneous.Theminimallygainedsegmentin ALLwas 57.4 Mb [dup(l)(q22q32.3)]. Satellite I1 DNA on Iq was not found to be hypomethylated,as previouslysuggestedfor otherneoplasmswith lq rearrangements. Globalgene expression studiesrevealedthat five genes in the minimallygainedregion,B4GALT3, DAP3, RGS16, TMEMI83A, and UCK2, were significantIyoverexpressedin dup(1q)-positiveALL compared with high-hyperdiploidALL without dup(I q) (Davidsson et al., 2007). The DAP3 proteinhas been reportedto be highly expressedin invasiveglioblastomamultifonnecells, whereasexpressionof the UCKZ proteinhas been correlatedwith sensitivityto anticancer drugs. However, this was the first reportof the involvementof these genes in dup(1q)positive ALL. Thereis no known effect on prognosisand,specificallyin high-hyperdiploid ALL, the presence of dup(1q) does not alter the good outcome associated with this cytogeneticsubgroup(Moormanet al., 2003).

t(l;19)(q23;p13.3) The t(1;19)(q23;p13.3)(Fig. 9.3) was first reportedto be an ALL-specificabnormalityin 1984 by three independentgroups (Carrollet al., 1984; Michael et al., 1984; Williams

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1

19

FIGURE9.3 Partialkaryogramfrom a pre-B ALL with t( 1 ;19)(q23;p13).

et al., 1984). Cytogenetically,it may occurin a balancedor an unbalancedform, in which the derivativechromosome 19 only is present (Secker-Walkeret al., 1992). The unbalanced form is the most common, accountingfor 75% of cases, althoughsome patients display both balanced and unbalancedtranslocations(Sheareret al., 2005). It has been proposedthatthe unbalancedform most likely arisesfroman initialtrisomy 1 followed by the translocationevent and the subsequentloss of the derivedchromosome1 (Paulsson et al., 2005a). The translocationleads to a fusion of the TCF3 gene (transcriptionfactor3, previously knownas E2A andITFl) at 19p13 with the PBXl (pre-Bcell leukemiahomeobox 1 ) gene at lq23 to form a TCF3-PBXl (Hungeret al.. 1991). In approximately5 1 0 %of cases with visible translocations,no apparentmolecular involvement of TCF3 and PBXI is found(Priviteraet al., 1992). This may result fromvariablebreakpointswithin the genes giving rise to an alternativeTCF3-PBXl fusion transcript(Paulssonet al., 2007). TCF3 encodes two transcriptionfactors, E l 2 and E47, which are requiredfor normallymphopoesis andregulationof B-cell development.The resultingaberrantproteinproductof the gene fusion affects cell differentiationarrestand leads to the developmentof leukemiain mice (Hunger, 1996). A rare variant,t( 17;19)(q22;p13), involving TCF3 has also been described(see below). Screeningby FISH with breakapartprobesspecific for TCF3 has providedthe opportunityto accuratelydetectcases with the TCF3-PBXI fusionas well as the rare variants(Barberet al., 2007). The t(1;19) is one of the most common translocationsin ALL, occurringin approximately 6%of cases overall. Fromcytogeneticsalone the frequencymay be lower, as the 6%incidence includes those cases detected by FISH and/or RT-PCR. It is generally associatedwith a pre-I3 immunophenotypewith blasts expressingCDlO and cytoplasmic immunoglobulin.Up to 25% of cases with this immunophenotypearereportedto have the translocation(Secker-Walker,1997). Patients with this abnormalityhave significantly higherWBC counts than do other ALL patients.The early associationof t( 1;19) with a poor outcome has been moderated by more aggressive therapy in modem protocols (Hunger, 1996; Kager et al., 2007). It remains unresolved whetherthe prognosisvaries between the presence of the balancedor unbalancedform of the translocation.SeckerWalker et al. (1992) described an improved outcome for patients with the unbalanced form.

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This translocationis a characteristicof Burkittlymphoma and mature B leukemia. It representsa variantof the t(8;14)(q24;q32)(see below).

t(4;ll)(q21;q23) The t(4;l I ) (Fig. 9.4) was first detectedby Oshimuraet al. (1977) and was subsequently described to be consistently associated with ALL by Van den Berghe et al. (1979). Additionalchromosomalchanges areoften found (-30%) in associationwith t(4;ll). The most common are gain of the X chromosome, i(7)(q10), and trisomy 8 (Johansson et al., 1998). The t(4;ll) leads to a fusion between the MLL gene (Rowley et al., 1990) and the AF4/ FMR2 family, member 1 gene AFFI (previously known as AF4, MLL72, and P B M I ) , generatingan MLL-AFFI transcript.The breakpointsin MLL clusterwithin an 8.3 kb region between exons 5 and 11. The pathogeneticallyessential transcriptis MLL-AFFI on the derivedchromosome11 , in which 5' MLL sequencesarefusedwith 3' sequencesfromAFFI (Gu et al., 1992; Domer et al., 1993; Downing et al., 1994). Variant and complex translocationsas well as submicroscopicinsertions have been described. There are a numberof otherwell-definedchromosomalabnormalitiesin ALL involvingtheMLL gene, manyof which arealso seen in AML (Chapter5). The most frequentare t(6;I l)(q27;q23), t(9;l l)(p21;q23),rearrangements between lOpl2andI lq23, andt(l1;19)(q23;~13.3).The fusion partnersare MLLT4 (AF6), MLLT3 (AFP), MLLTIO (AFIO), and MLLTl (ENL), respectively.These will be discussed in the relevantsections below. Almost 90 different 1 lq23 rearrangements have been reported,and at least 51 differentMLL fusions encoding chimericproteinsin which the N-terminalportionof MLL is fusedto the C-terminalportion of the new partnerhave been identified (reviewed in Meyer et al., 2006). The common translocationsinvolving M U can in most instancesbe identifiedby chromosomebanding cytogenetics.They may also be detectedby RT-PCRusing a rangeof primers(Pallisgaard et a]., 1998). However, a dual-colorFISH approachhas proved to be the most reliable detectionmethod(Harrisonet al., 2005). FISHusing a breakapart probeAankingthe M U will detect the multiplepartnersas well as those of a cryptic nature,for example those

4

FIGURE 9.4

11

Partial karyogram from a pre-B ALL with t(4; 1 1 )(q21;q23).

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involving insertionevents (Harrisonet al., 2005). This methodhas also been useful for the detectionof those translocations,primarilyof t(4;ll) and t(6;11), in which concurrent3’ MLL deletions occur (Barberet al., 2004a). However, as the probe is large, covering sequencesboth 3’ and 5’ of M E ,alternativemethodsmay be required(such as Southern blotting)to determinewhetherthe deletion involves only partof or the entiregene. Chromosomalrearrangements involving MLL are stronglyassociatedwith infantALL, accountingfor up to 85% of cases in that age group (Biondi et al., 2000). Althoughonly 2-3% of pediatricALL is diagnosedin patientsyoungerthan 12 monthsof age, it has been reportedthat infantscomprise60%of all t(4;I 1)-positivechildhoodcases ( h i , 1992). In contrast,the incidencesin childrenbetweenthe ages of I and 15 yearsand in adultsareonly roughly 2 and 5%,respectively(Harrisonet al., 2005; Moormanet al., 2007a). In all age groups,the t(4;1 I ) is the most frequentlyobservedMLLrearrangement(Pieterset al., 2007), whereast(4;ll) is rareamongMLL-positiveAML (Chapter5). MLLfusionsarealso rarein T-ALL, accountingfor about5%.The most frequentpartnersin T-ALL areMLLTZ in the t( 1 1;19)(q23;p13.3) and MLLT4 in the t(6;I l)(q27;q23) (Hayetteet al., 2002). ALL with t(4;1 1) usuallyhave an earlyB-precursorimmunophenotype,beingnegative for CDI0 and positive for CD 19. Females are overrepresented,and the patientscharacteristicallyhave a high WBC count, a high percentageof blasts in the peripheralblood, organomegaly,and CNS involvement.Overall,the outcome is extremelypoor, although significantlybetterin childrenaged 2-9 years comparedto infants, very young children, and patientsover the age of 10 years including adults(Heeremaet al., 1994; Johansson et al., 1998; Hann et al., 2001; Moorman el al., 2007a). The presence of additional chromosomal changes has no impact on outcome in MLL-positive childhood ALL (Moormanet al., 2005).

t(5;W(q=;q32) This cytogeneticallycryptictranslocationis found only in T-ALL. It comprisesapproximately20%of childhoodand 13%of adultcases (Bergeret al., 2003). The t(5;14) involves the TLX3 and BCLlIB genes. TLX3 (T-cell leukemiahomeobox 3, previouslyknown as HOX1 ZL2 and RNX) in 5q35 belongs to the class II homeobox gene family.The Kriippellike zinc-fingergene BCLZZB (B-cell CLUlymphoma1 lB, zinc finger protein)in 14q32 encodes a transcriptionfactor essential in T-cell development (Wakabayashiet al., 2003). As a resultof the translocation,BCLlIB specifically associateswith TLX3 leading to its upregulation(Bernardet al., 2001; Su et al., 2006b). Rarevariantsas well as subtle genomic deletions and insertionswithin 5q have been reported(Bergeret al., 2003; Su et al., 2004). These observationshave highlightedthat TwC3 expressionin T-ALLrarely occurs in the absenceof 5q abnormalities.Thus,FISH using a breakapartprobetargeting TLX3 providesa reliable detectionmethod. The occasional findings of t(5;14)(q35;qI1) juxtaposing TLX3 and T W R D (Hansen-Haggeet al., 2002). and t(5;7)(q35;q21)and t(2;5)(p21;q35) involving TLX3 with CDK6 (cyclin dependentkinase 6) and an as yet uncharacterizedlocus on 2p21, respectively (Berger et al., 2003), indicate that the regulatoryelements of TCR or other genes may also contributeto the upregulationof TLX3. There is an increasingnumberof reportsof the involvementof BCLIIB in other rearrangementsin T-ALL, for example, t(5;14)(q35.1;q32.2),in which NKX2-5 (NK2 transcription factorrelatedlocus 5), anotherhomeoboxgene locatedto 5q35, is upregulated (Nagel et al., 2003) with absence of the wild-type BCLZIB transcript(Przybylski

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et al., 2005). TWC3-expressingT-ALL do not have the favorable outcome generally associated with TLXI expression (see below) (Ballerini et al., 2002; Ferrandoet al., 2002; Cave et al., 2004).

W6q) Deletionsof the long arm of chromosome6 occur in 5 1 3 %of ALL cases in both B- and T-ALL,usuallyin associationwith otherabnormalities.They arecharacteristicof lymphoid malignancies in general, being common also in chronic lymphoproliferativedisorders and non-Hodgkinlymphomas(Chapter10). The breakpointassignmentof del(6q) from cytogeneticanalysis, loss of heterozygosity(LOH)studies,and,morerecently,aCGHhas variedconsiderably(reviewedin Sinclairet al., 2004; Streffordet al., 2007). Thebandsmost frequentlyreportedas the breakpointsites are 6q15-21. As for all neoplasia-associated terminaldeletions examined,the 6q deletionsactuallyare interstitial,even in those cases where the microscopic impressionis that it is terminal (Menasce et al., 1994). As the assignmentof a commonly deleted region has not been possible, this questionsloss of a single tumorsuppressorgene as the pathogeneticconsequenceof del(6q). The strongest candidate reported so far is the kainite receptor gene, GRZKZ (glutamate receptor, ionotropic,kainite 2, previouslyknown as GLURQ, in 6q 16 (Sinclairet al., 2004). No specificclinicalassociationshavebeen madewith del(6q)in B-lineageALL.Overall, most del(6q)-positivecases occurin the commonALL subgroup.Only rarelyhasALL with del(6q) displayed a matureBcell phenotypeand belonged to the L3 subgroupmerger and Bernheim,1985). There is no clear-cutevidence for a prognosticimpactof del(6q) in ALL.

t(6;7)(q23;q34) and MYB Duplication Theseabnormalitiesarefoundexclusivelyin T-ALL,occurringin approximately10%of TALLcases in very youngpatients(median2.2 years).TheMYB (v-mybmyeloblastosisviral oncogenehomologue (avian),previously known as c-myb) oncogene in 6q23.3 encodes a nucleartranscriptionfactorthat is implicatedin proliferation,survival,and diffepntiation of hematopoieticprogenitorcells. In the t(6;7), MYB is juxtaposed to TRB (Clappier et al., 2007) leading to upregulationof MYB expression.A short somatic duplicationof 230 kb in 6q23 specifically targetingMYB also producesa three-fold overexpressionof MYB mRNA. (Clappieret al., 2007; Lahortigaet al., 2007). These findings identified amplificationof MYB as an oncogenicevent andhighlightedMYB as a possible therapeutic targetin T-ALL.Currently,no clinical associationshave been found,perhapsbecause the numberof reportedcases is small.

t(6;l l)(q27;q23) In thistranslocationtheMLLT4 gene at 6q27 is the partnerof MLLat 1lq23. It occursmainly in AML (see Chapter5) but has also been reportedin a handfulof ALL of both B- and Tlineages(Martineauet al., 1998;Hayetteet al., 2002). The t(6;11) is frequentlyseen as the sole cytogenetic change. When additionalabnormalitiesare present,they are generally numericalratherthan structural.As in t(4;1 1)-positivecases, the t(6;ll) may be accompanied by a concurrent3’ M U deletion(Martineauet al., 1998; Barberet al., 2004a). Similar to AML with t(6;1 I), ALL with this translocationhas been associatedwith a shortmedian

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overall survivaland,hence, a poorprognosis,althoughnumbersof patientsareusually too small to be analyzed separatelyfrom other MLL translocations.

t(6;14)(p22;q32) This translocationmay be difficultto visualizeby chromosomebanding,hence metaphase FISHwith an ZGH breakapart probeis useful foraccurateidentification.Thekaryotypesof t(6;14)-positive ALL aregenerallycomplex and often harbori(9)(q10) (see below). The t(6;14) brings the ZGH enhancerat 14q32 into proximitywith the ID4 gene (inhibitorof DNA binding 4, dominantnegative helix-loop-helix protein)at 6p22, with breakpoints scatteredovera I9 kbregioncentromericof thisgene. QuantitativePCR showsupregulation of 104 mRNA (Russell et al., 2008). The 104 gene is one of four membersof the basic helix-loophelix (bHLH)family of transcriptionfactorsId-1, Id-2,Id-3,andid-4, whichact as transcriptioninhibitoryproteins. In total, 15 cases with the t(6;14) have been describedto date (Pui et al., 1992; Bellido et al., 2003; Russellet al., 2008). All hada pre-Bimmunophenotype. The WBC countswere generally low and the patients were older than expected for ALL (median 14 years). Althoughnumbersaresmall, the outcomefor these patientsappearsto be relativelygood. Thisraresubgroupaddsto thegrowingnumberof ZGH partnersdescribedin pre-BALL(see t( 14;19)(q32;ql3)for otherexamples).

inv(7)(pl5q34)/t(7;7)(pl5;q34)/t(7;14)(pl5;qll)/t(7;14)(pl5;q32) Theseabnormalitiesarecharacteristicof T-ALL.The inv(7), which is oftencytogenetically cryptic,andthe t(7;7)bringthe TRB enhancerwithinthe HOXA (homeoboxA cluster)locus at 7p15 (Soulieret al., 2005; Spelemanet al., 2005). Thereare also rarereportsof HOXA involved in complex rearrangementswith TCR genes (Cauwelieret al., 2007). HOXA rearrangementshave been identified by FISH in up to 3% of T-ALL. They lead to upregulationof genes in the HOXA cluster,especially HOXAlO andHOXAf I . HOXA has also been seen to be upregulatedby TRD (Bergeronet al., 2006) andBCLf ZB, specifically HOAX13 (Su et al., 2006a), in the t(7;14)(p15;qlI) and t(7;14)(p15;q32),respectively. Homeobox (HOX) genes encode transcriptionfactors which act as key regulatorsin embryonicdevelopmentand normalhematopoiesis(van Oostveenet al., 1999). They are dividedinto two classes. Class I HOX genes comprise39 genes distributedin fourclusters (A-D) locatedin 7p15,17q21,12qI3, and 2q31, respectively.Class I1 homeoboxgenes are the divergenthomeoboxgenes with less homology.Clinicaland prognosticassociationsof HOX genes in T-ALL havenot been possible due to the rarityof these abnormalities.

Chromosome9 is frequentlyinvolvedin the formationof dicentricchromosomesleadingto loss of 9p materialas well as a deletionof the partnerchromosome.The dic(7;9) is a rare abnormalityin B-lineage ALL having been described in less than 30 cases. Although usually seen as the sole abnormality,it has also been reportedin associationwith t(9;22) (q34;qll). ArrayCGH examinationof threecases showed the breakpointsto be clustered within 9 ~ 1 3 . 1and 7pl1.2-p12.1 (Lundinet al., 2007). It remainsunknownwhetherthe pathogeneticallyimportantoutcomeof thedic(7;9)is formationof achimericgene orloss of

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7p and/or9p material.No prognosticassociationshavebeenassigned,althoughthe outcome appearsto be quite heterogeneous.

This isochromosomeis relativelycommonin ALL, with approximately100 cases having been described.It has been reportedthat i(7)(q10) is not a true isochromosomebut an isodicentricabnormalitywith breakpointsin proximal7p (Schaadet al., 2006). It is usually associatedwith othercytogeneticchangesindicatingthat it is a secondaryabnormality.In the majorityof cases, t( 1;19), t(4;l l), or high hyperdiploidyis the primaryaberration.The leukemia is mostly pre-B ALL ( h i et al., 1992). No other distinguishinglaboratoryor clinical featurescharacterizethis cytogeneticsubgroup.

Althoughdysregulationof the TALI gene occurs in almost 25% of patientswith T-ALL, upregulationof the TAL2 gene (T-cell acutelymphocyticleukemia2) in T-ALL,as a result of the t(7;9)(q34;q32), is rare. This translocationjuxtaposes TAL2 and TRB (Xia et al., 1991). The TAL2 gene productincludesa helix-loophelix proteindimerand DNA bindingdomainthatis homologous to those encodedby TALI (see above) and LYLl (see below). Hence, TAL2, TALI, and LYLl constitutea discretesubgroupof helix-loophelix proteinencodinggenes thatcontributeto the developmentof T-ALL.TAL2 transcriptionis activatedectopically in lymphoidcells and the inappropriateexpressionof TAL2 in these cells promotesdevelopmentof T-ALL.Normally,the TAL genes are not expressedin the thymus.The TAL genes becomeactivatedandexpressedin the thymusuponchromosomal translocationthatultimatelyleads to the developmentof T-ALL.As the propertiesof TAL2 broadlyresemble those describedpreviously for TALI, this supportsthe idea that both encoded proteinspromoteT-ALL by a common mechanism.

t(7;9)(q34;q34.3) In the rarely occurringt(7;9)(q34;q34.3)of T-ALL, the NOTCH1 (Notch homologue 1, translocationassociated(Drosophila),previouslyknown as TANI) gene in 9q34.3 formsa fusion with TRB resultingin aberrantexpressionof a truncatedactivatedformof NOTCH] (Ellisen et al., 1991). The translocationprovides a good example that cloning of rare abnormalitiesis valuableto revealgenes of significance,in this case NOTCHl. Activating mutationsof the HD (heterodimerization)and PEST domains (polypeptidesequences enrichedin proline(P),glutamate(E), serine(S), andthreonine(T),proposedto expeditethe degradationof proteins)of NOTCH] occurfrequentlyin T-ALL,being foundin morethan 50%of cases. Thereis evidencethatNOTCH1 mutationsareearly,prenatalgeneticeventsin T-ALL(Eguchi-Ishimaeet al., 2008). NOTCH1 is a directregulatorof cell growth,playinga criticalrole in T-cell development(Weng et al., 2006). NOTCH1 acts cooperativelywith oncogene transcriptionfactorsin T-ALLpathogenesis,providingan exampleof multistep developmentof T-ALL(Zhuet al., 2006). Forexample,MYC is an importantdownstream target of NOTCH1 in normal pre-T cell developmentas well as in T-ALL (Maillard et al., 2005). It has been shownthatthe NF-kappapathwayis highly activein established human T-ALL. Constitutivelyactive NOTCH 1 activates the NF-kappaBpathway transcriptionallyand via the IkappaB kinase ( I S ) complex, thereby causing increased

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expression of several well-characterizedtarget genes of NF-kappaBin bone marrow hematopoieticstem cells and progenitors.Inhibitionof the pathway efficiently restricts tumorgrowthboth in vitro and in vivo. These findings identify NF-kappaBas one of the major mediatorsof NOTCHI -induced transformationand suggest that the NF-kappaB pathwayis a potentialtargetof futuretherapiesof T-ALL(Vilimaset al., 2007). NOTCHI mutationsareassociatedwith shortsurvivalin adultsbutnot in children(Weng et al., 2004; Lee et al., 2005; Mansouret al., 2006).

t(7;l O)(q34;q24) The t(7;lO)representsararevariantoft(10;14)(q24;qI I). Int(7;10),TLXI(T-cellleukemia homeobox 1, previously known as HOXIl) gene is juxtaposed with TRB (Cauwelier et al., 2006). Genomic rearrangementsof the TRB occur in 19% of T-ALL, providing alternativeupregulationof oncogenes in this disease (see t( 10;14) below).

t(7;ll)(q34;pl3)/t(7;1 l)(q34;p15) These translocationsoccurin T-ALLand involve TRB with the genes LMOI (LIMdomain only l(rhombotinI), previouslyknown as RBTNI, i"TG1, and RHOMI) and LM02 (LIM domain only 2 (rhombotin-likel),previously known as RBTN2, 77G2 and RHOM2) in 1lp13 and I lp15,respectively(Cauwelieretal.,2006).LM01andLM02areupregulatedin T-ALL,andtheirelevatedexpressionwithindefinedgene expressionsignaturesis indicative of leukemicarrestat specific stages of normalthymocytedevelopment.These are used to define the molecular pathways involved in the pathogenesis of T-ALL (Ferrando et al., 2002) (for more discussion, see t(l1;14)(p13;qlI)/t(l1;14)(p15;qll) below).

t(7;12)(q34;pl3.3) In T-ALLwith t(7;12)or t(12;14)(p13.3;q1 1) (see below), massiveupregulationof CCND2 (cyclin D2) is producedby translocationto TRB andTRA, respectively.Thesetranslocations areextremelyrare,thustheirspecificclinicalassociationsareunknown.However,theirhigh expressionis associatedwith overexpressionof TALI,TLX1, TLX3,NOTCH1 mutations, and CDKN2A deletions, indicatinga role for CCND2 in the multistepleukemogenesisof T-ALL (Clappieret al., 2006).

t(7;12)(q36;pl3) A small numberof infantB-lineageALL cases with a cytogeneticallycryptict(7;12) have been reported(Tosi et al., 2000; Slateret al., 2001; von Berghet al., 2006). It is oftenfoundin associationwith trisomiesof chromosomes8 and 19, which may providea markerfor the presenceof thiscrypticabnormality.It is morecommonin infantAML, in which it is found in approximately20% of the cases. Thus, the cytogenetic associations,molecularconsequences,and clinical implicationsaredescribedin detail in Chapter5.

t(7;19)(q34;pl3) The t(7;19) is a rare translocationin T-ALL. In this translocation,LYLl (lymphoblastic leukemia derived sequence 1) in 1 9 ~ 1 3recombines with TRB leading to LYLl

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overexpression(Mellentinet al., 1989). LYLl encodes a protein with a potentialhelixloophelix DNA binding motif that is a regulatorof transcription.The gene is also constitutivelyoverexpressedin a subset of T-ALL without the translocation(Fernando et al., 2002). T-ALL with LYLl overexpression shows an immaturephenotype and is associatedwith a poor prognosis.

t(8;14)(ql1;q32) The first t(8;14) foundin BCP-ALLwas reportedby Kardonet al. (1982). At least 45 cases have now been described.The involvementof theIGH locus was demonstratedby Southern blotting(Testoniet al., 1993) as well as FWH (Byattet al., 2001). The partnergene at 8q I 1 was recently found to be CEBPD, one of the CCAATlenhancerbinding protein (CEBP) family members, which are a family of six multifunctionalbasic leucine zipper (bZIP) transcriptionfactors.CEBPD is overexpressedas a resultof this translocation,revealingan oncogenic role for this gene in BCP-ALL (Akasakaet al., 2007). Fourother CEPB gene family membershavebeen describedas ZGH partnersin ALL, namelyCEBPA and CEBPC [t(14;19)(q32;q13)], CEBPE [inv(14)(ql lq32)/t(14;14)(ql1;q32)], and CEBPB [t(14;20) (q32;q13)1. These are describedbelow underthe appropriateheadings. A substantialproportion(25%) of t(8;14)-positiveALLs occur in patientswith Down syndrome.Furthermore,in a numberof non-Down syndromepatients,the translocation t(9;22)(q34;q11)has been found (Kaleem et al., 2000; Byatt et al., 2001; Akasaka et al., 2007). In one patientwith a relapsesample, the t(9;22) was presentwhereasthere was no evidence of the t(8;14), providingevidence that the t(8;14) was secondaryto the t(9;22) in this case (Byatt et al., 2001). All cases with t(8;14) have had a pre-B immunophenotype.The groupcomprisesolder children(medianage around10 years) as well as adults.The WBC counts arevariable.Althoughthe numberof cases is small, overall the survivaldatado not associate this abnormalitywith an increasedrisk of relapse.

The t(8;14)(q24;qll) is a rarelyreportedtranslocationin T-ALL.In the majorityof cases, the oncogene MYC at 8q24 is recombinedwith T C M D or, rarely,with TRB promotersin case of a t(7;8)(q34;q24).The breakpointin MYC lies 3’ of the thirdexon as in the variant Burkitt-specifictranslocationst(2;8) and t(8;22) (see below and Chapter10). The breakpoint in TRA lies just 5’ of one of the J segments (Eriksonet al., 1986). The molecular characteristicsof the translocationare hence similarto those of matureB-cell neoplasms with recombinationsbetween8q24and 14q32,2p1 1 or22q 1 1, in whichMYCis upregulated (see below). Patientswith t(8;14)-positiveT-ALLaremoreoftenmale thanfemale andtendto have a high WBCcountandbulkyextramedullary leukemia.CNS involvementis seen at diagnosis in one thirdof the cases (Langeet al., 1992).Theoutcomeforpatientswiththistranslocation is unknowndue to the rarityof its occurrence.

The t(8;14) and its variantst(2;8)(pI l;q24) andt(8;22)(q24;q1 1) areassociatedwith B-cell neoplasia(Bergerand Bernheim,1985). The translocationswere first describedand have been mostextensivelystudiedin Burkittlymphoma,andthereaderis referredto ChapterI0

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for a detailedcytogeneticdescription.In summary,the crucialevent in all threetranslocations is the juxtaposingof MYC (from 8q24) and either the IGH locus (l4q32), the IGK immunoglobulinkappalight-chainlocus (2p I2), or the IGLimmunoglobulinlambdalightchain locus (22q I I ). Throughone of theserearrangements, MYC comes underthe influence of the transcriptional promotersequencesandenhancerelementsin theconstitutivelyactive immunoglobulinlocus. This in turn leads to deregulationand increasedtranscriptionof MYC. ALL with t(8;14) orthevariantst(8;22)andt(2;8)is almostalwaysof L3 morphologyand matureB-ALL. In fact, no abnormalitiesother than these three translocationshave been associated with L3 leukemiawith any consistency.The t(8;14) is most common, found in 85%. whereast(2;8) and t(8;22) are found in around5 and 10%.respectively.

t(8;22)(q24;qll) Thistranslocationis characteristicfor BurkittIeukemiaAymphoma. It representsavariantof the t(8;14)(q24;q32)(see above).

del(9p) Chromosomalabnormalitiesleadingto deletions of 9p in ALL were firstdescribedin the 1980s (Kowalczykand Sandberg,1983; Chilcoteet al., 1985;Maseki et al., 1986;Carroll et al., 1987a).Sometimesthe loss was shownto be homozygous(Diaz et al., 1990;Heyman et al., 1993). The majorityof visible 9p abnormalitiesresult in deletion of 9p21. This chromosomebandcontainstwo tandemlylinkedgenes thatencodecyclin-dependentkinase inhibitors, namely CDKN2A (previously p16) and CDKN2B (previously p15). The CDKN2A locus also codes for PI&RF (Quelle et al., 1995). It has subsequentlybecome clearthatCDKN2A is the primarytargetof 9p2 I deletionsin ALL.Inactivationof CDKN2A can occur by hypermethylationor mutationat both the transcriptionaland posttranscriptionallevels as well as by deletion(Ohnishiet al., 1995;Chimet al., 2003).Publishedreports are inconsistentin terms of incidence and route of inactivation.However, mutationsor methylationof CDKNZA is quiterarein comparisonto deletions.At the molecularlevel, the deletionshave been shown to vary significantlyin size, fromsingle exons to largegenomic regions, and to targetone or both alleles. Additionalgenes can be incidentallyco-deleted. For example, CDKN2B is deleted in a significant proportionof ALL but always in associationwith CDKN2A (Bertinet al., 2003). This is also the case for the methylthioadenosinephosphorylasegene, MTAP, which is locatedapproximatelyI 0 0 kb telomericto CDKN2A. FISH providesan excellent method for detectingthe majorityof both homozygous and hemizygousdeletions with the addedadvantageof providinginsightinto tumor heterogeneity.Deletionsof 9p usuallyoccuras a secondarychangeandareassociatedwith all otherprimarygenetic abnormalitiesin both B- and T-ALL, althoughin the latter,the functionalinactivationof CDKN2A in the majorityof cases implies a directinvolvementin T-cell leukemogenesis(De Keersmaeckeret al., 2005b). In childhood ALL, cytogenetically visible 9p abnormalitiesoccur at an incidence of approximately10%(Heeremaet al., 1999b), whereas CDKN2A inactivationis found in morethan20%of B- and50%of T-lineagechildhoodALL (Drexler,1998). The frequency of CDKN2A inactivationis strongly correlatedwith cytogenetic subgroups,with lower frequenciesbeing observed among cases with high hyperdiploidyor the ETVGRUNXI fusion.WithinBCP-ALL,olderchildren(over 10 years)aremorelikely to havebothvisible

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9p abnormalitiesand CDKN2A inactivation,whereasthe reverseis truein T-ALL. Patients with ALL with CDKN2A deletionshave higherWBC countsand a more “lymphomatous” leukemia than otherchildren with ALL. Survival analysis has shown reduced event-free survival in patients with visible 9p abnormalities(Hann et al., 2001 ). However, the picture concerning the prognostic significance of CDKN2A deletions is currently unclear. They have been associated with a poor outcome in both B-lineage and T-ALL, but generally the literatureis contradictory(Zhouet al., 1997; Drexler, 1998; Carteret al., 2001; Soenen et al., 2001; Zuna et al., 2002; Lemos et al., 2003). One reportclaims that alterationsin CDKN2B but not CDKN2A are a poor risk factorin adult B-lineage ALL (Hoshino et al., 2002). The most consistent poor risk associations are with T-ALL in adults (Yamadaet al., 1997) and children(Fizzotti et al., 1995; Diccianni et al., 1997). Moreconvincing recentdatahave indicatedthat deletion of CDKN2A, with and withoutdeletions of CDKN2B and MTAP, is not linked to a poor outcome in childhood B-lineage ALL (Mirebeauet al., 2006). The observationof a negative correlationbetween CDKN2A inactivationand low-risk cytogenetic subgroupsmay explain why it has been inconsistentlyassociatedwith a poor prognosis. , is a transcriptionfacThere has been much interest inthe PAX5 gene at 9 ~ 1 3which tor essential for B-lineage development. A high-resolutionSNP arraystudy of a large series of childhood BCP-ALL showed deletion, amplification, point mutation, and structuralrearrangementof PAX5 in 30% of the cases (Mullighan et al., 2007). The majorityof PAX5 deletions involved only a subset of exons, leading to the encoding of an internally deleted PAX5 protein in a dominant leukemic clone, consistent with a role in leukemogenesis.Deletions were also detectedin otherregulatorsof B-lymphocyte developmentand differentiation,that is, TCF3, EBFI, U F I , IKZFI, and IKZF3. These findingssuggest that deletion or other mechanismsleading to disruptionof these genes may: (1) contributeto theblock in differentiationthatis a hallmarkof ALLand(2) produce direct disruptionof pathwayscontrolling B-cell development and differentiation,thus contributingto B-progenitorALL pathogenesis.These abnormalitieswere found among all cytogenetic subgroups and have not yet been shown to have any association with outcome. A numberof deletionsof 9p includeJAK2 (Januskinase2, a proteintyrosinekinase)at 9p24. Althoughthis gene is essentialfor thetransmissionof signalsfromcytokinereceptors to downstream signaling, and it is known that mutations play a significant role in myeloproliferativedisorders,it has not been proposedas a targetof 9p deletions in ALL. However,a role in Down syndrome-associatedALL is emergingwith the recentdiscovery of JAK2 mutationsin 20% of such cases; no mutationshave been observedin non-Down syndromeALL (Ganmoreet al., 2007).

In one case of pediatricT-ALL, a t(9;12)(p24;p13) was shown to fuse the 3’ portion of JAK2 to the 5‘ region of ETV6 leading to the formationof an ETV6-JAK2 fusion. The fusion protein included the catalytic domain of JAK2 and the ETV6-specific oligomerizationdomain. ETV6-inducedoligomerizationof ETV6-JAK2resultedin the constitutiveactivationof its tyrosine kinaseactivity andconferredcytokine-independent proliferationon the interleukin-3-dependentBa/F3 hematopoieticcell line (Lacronique et al., 1997).

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dic(9;12)(pl1-12;pll-l3) Since the first reportof dic(9;12) in eight pediatricALL (Carrollet al., 1987b),close to 50 cases have been describedyielding an incidenceof approximately1% in childhoodALL. The breakpointpositionsin 9p have been shown to varyconsiderablyat the molecularlevel (Pellet et al., 1991), althoughFISH and molecularstudieshave shown thatthe abnormality can give rise to a fusion betweenE W 6 on 12p13 andPAX5 at 9p1 3 (Cazzanigaet al., 200 1 ; Strehl et al., 2003). These were the first reports of PAX5 rearrangementsin human malignancyresulting in a chimeric transcript.It contains the NH(2)-terminalregion of PAX5 andmost of the E m 6 gene on I2p13. TheresultingchimericproteinretainsthePAX5 paired-boxdomainandboththe helix-loophelix andDNA bindingdomainsof ETV6.The PAXS-ETV6proteinactsas an aberranttranscriptionfactorwith repressorfunction,leading to a block in B-cell differentiation(Fazio et al., 2008). As dic(9;12) is an unbalanced translocation,theETV6-PAX5transcriptis not present.Thedicentricchromosomehasbeen foundin associationwith otherchromosomalchangesand,amongother12pabnormalities, it has been found in association with the ETV6-RUNX1 fusion (see below) (Raynaud et al., 1999). ALL with dic(9;12) has a pre-B immunophenotype,apartfroma single case with Tcell immunophenotype (Behrendtet al., I995), anda strikingmalepredominance.Theyoccurin all age groups and have been suggested to have an excellent prognosis (Mahmoud et al., 1992; UKCCG, 1992). The associationwith the ETV6-RUNXI fusion may partly accountfor the favorableoutcome.

dic(9;20)(p13;qll) The dic(9;20) was first reportedin the mid-1990s (Riederet al., 1995; Slateret al., 1995) and,since then,approximatelySOcases havebeen described,constituting1.3%of pediatric BCP-ALL (reviewed in Forestier et al., 2008a). FISH with chromosome 9 and 20 centromericprobesis often requiredfor accuratedetectionas the dic(9;20)may be difficult to identify cytogenetically.It manifestsas monosomy 20, sometimeswith a 9p deletion (Clarket al., 2000). High-resolutionaCGHhasshownthat,althoughthe breakpointscluster to subbands9p 13.2 and 20q I 1.2, they are not identical, suggesting that the functional outcome of the aberrationis loss of genetic material rather than a consistent gene rearrangement(Schoumanset al., 2006; Streffordet al., 2007). All cases have modal chromosomenumbersbetween44 and 50. Additionalchromosomalchangesarepresentin 60%of cases, the most frequentof which are hemi- or homozygousloss of CDKN2A and gains of chromosomes21 and X. The dic(9;20) more frequentlyoccurs in pediatricALL with approximately90% of the reportedcases being childrenor adolescents.The median age is 3 years, with a female predominance.Although the event-free survival is not particularlyfavorable, with mostly early relapses, the post-relapse treatmentof many patientsis successful, yielding a ratherfavorableoverall survival.

i(9)(qlO) The largestseriesof isochromosomeswas reviewedby h i et al. ( 1992).lsochromosomefor the long arm of chromosome9 has been reportedin more than 100 cases. It is usually associatedwith otherchromosomalaberrations,forexamplet( I; 19)(q23;p13).As described for i(7)(q10) (Schaad et al., 2006), it is possible that i(9)(q10) is also an isodicentric

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chromosome,althoughthis has not been proven.The i(9q) resultsin hemizygousdeletions of PAX5 (pairedbox 5) and CDKN2A (cyclin-dependentkinaseinhibitor2A). In a number of patients,the deletion of CDKN2A is homozygouswith the second allele being lost as a resultof a cryptic9p deletion.Childrenwith ALLharboringi(9)(q10)are,on average,older thanotherchildrenwithALLandtheirleukemiamoreoftenhas a pre-Bimmunophenotype, althoughrarecases of T-ALLhavebeen reported.The incidenceis equivalentin males and females, and the WBC count is highly variable. There are no particularprognostic associations.

t(9;9)(q34;qW ABLl is a ubiquitouslyexpressedcytoplasmictyrosinekinaseencodedby theABLl (v-abl, Abelson murineleukemiaviraloncogenehomologue 1, previouslyknownas ABL) gene in 9q34. Althoughthe BCR-ABLI fusion of chronicmyeloid leukemiaandB-lineageALL is exceptionallyrarein T-ALL, an alternativeABLl fusion with NUP214 (nucleoporin214 kDa, previouslyknown as CAN) has been describedas a secondaryabnormalityin 6% of T-ALL (Burmeisteret al., 2006). The primaryabnormalitiesincluded t( 10;14)(q24;ql1) (see below) and t(5; 14)(q35;q32)(see above). The t(9;9) was initially discoveredby FISH screeningfor evidence of the BCR-ABLI fusion, which revealed multiple extrachromosomalABLl signals on episomes (Barber et al., 2004b;Grauxet al., 2004) and,rarely,homogeneouslystainingregions(hsr)(Ballerini et al., 2005). The episomes are not seen as double minutes and are not visible at the cytogeneticlevel. An in-framefusion between introns23-34 of NUP214 and intron 1 of ABLl was identified in cases with this abnormality.This finding was compatiblewith a model in which the genomic region fromABLl to NUP214 was circularizedto providethe NUP214-ABLI fusion. The copy numberof the episome is increased due to unequal segregationduringcell division. The NUP214-ABLI fusion is associatedwith increased HOX expression (Fernandoet al., 2002) as well as with deletion of CDKN2A (Hebert et al., 1994), consistentwith a multisteppathogenesisof T-ALL.NUP214-ABLI-positive and -negativeT-ALLpatientsdo not differsignificantlyin theirmajorclinical featuresand no significantdifferencein overallsurvivalhasbeenobserved(Burmeisteret al., 2006). Like BCR-ABL1,NUP214-ABLl acts as a constitutivelyphosphorylatedtyrosinekinase,which is also sensitive to imatinib,a selective inhibitorof ABLl kinase activity, as discussed in Chapter7. However, in a recently publishedcase, the NUP214-ABLI positive patient showed no responseto imatinibtreatment(Stergianouet al., 2005).

t(9;l o)(q34;q22.3) A single pre-B ALL with t(9;10)(q34;q22.3) has been reported(Soler et al., 2008). The translocationled to an in-framefusion of exon 2 of ABLl with exon 14 of ZMZZI(Zinc finger,MIZ-typecontaining 1 , previously known as MI?) at IOq22, producinga ZMZZIABLl fusion. Althoughonly a single case, it is of interestas it adds to the increasinglist of ABLl fusion partnersin acute leukemia.

t(9;ll)(p21;q23) Thet(9;1 l)(p21;q23)is anothertranslocationinvolvingtheMLLgene at 11q23 with MLLT3 on the shortarmof chromosome9. Only a smallnumberof cases havebeen reportedin ALL; this abnormalityoccurs predominantlyin Ah4L and is discussed in detail in Chapter5.

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Thecryptict(9;14)(q34;q32)encodinganEMLI-ABL 1 fusionproteinis anotherrareABLl fusion with EMLl (echinodermmicrotubuleassociatedproteinlike 1) at 14q32in T-ALL reportedin a single case (De Keersmaeckeret al., 2005a). It also had a deletionof CDKN2A and expressionof TLXl consistentwith a multisteppathogenesisof T-ALL.

t(9;22)(q34;qll) The t(9;22) results in formationof the Philadelphiachromosome(Ph) seen in chronic myeloid leukemia (CML) and, much less frequently,in AML (see Chapters5 and 7). Complex and cryptic varianttranslocationsmay occur in Ph-positive ALL as they do in CML,but in ALL the translocationis often accompaniedby a second copy of the derived chromosome 22. As well as this abnormality,other secondary changes include high hyperdiploidywith trisomy for chromosome 2. It is importantthat the Philadelphia chromosome is identified in these cases, as the prognosis reflects the presence of the t(9;22)ratherthanthe low riskassociatedwith classicalhigh hyperdiploidy.It is evidentthat the secondarychangesdifferfrom those of CML.As in CML,the translocationjoins the 5’ sequencesof the BCR gene at 22qll to the 3’ sequencesof ABW at 9q34, giving rise to the BCR-ABLI fusion. The breakpointoccurs between exons 1 and 2 (ela2) of BCR in the minorbreakpointclusterregion, m-bcr, and between exons I and 2 of ABLl (eIa2). This generatesa 7-kb mRNA andexpressionof a P190 protein(Clarket al., 1988). Alternatively, breakpointsin the BCR gene occur within a 5.8 kb region termedthe major breakpoint clusterregion (M-bcr),between eitherexons 13 and 14 (b2a2) or exons 14 and 15 (b3a2). This transcribesan aberrant8.5 kb mRNA encodinga chimericP210 protein(Groffenand Heisterkamp,1987) that arises frequentlyin CML (Chapter7). Both BCR-ABL1 fusion proteinsfunction as abnormallyand constitutivelyactivatedtyrosine kinases. They act throughthe SRChomology 2 (SH2) domain,the GRB-2bindingsite of BCR, andthe major autophosphorylation site of the kinase domain,primingintracellularsignaling leading to activationof genes alongthe RAS and CDKl pathway.This activityprovidesthe core of the transformingcapacityof BCR-ABLI. In a small numberof ALL patients,the t(9;22) is not visible by conventionalcytogenetic analysis,althoughthe BCR-ABLItranscriptis detectableby RT-PCR(Radichet al., 1994). These are known as Ph-negativelBCR-ABLIpositive ALL (Van Rhee el al., 1995). They arise from a submicroscopicrearrangementor are masked within a variantor complex karyotype.As an alternativeto RT-PCR,the translocationcan be readilyidentifiedby dualcolor FISH, particularlywhen it is cryptic.These alternativeapproacheswere reviewedby Kearney(1999). They have been particularlyuseful in the identificationof Ph-negative/ BCR-ABL1positive ALL and the presenceof BCR and/orABLl deletionsfromthe ABLIBCR region of the derivedchromosome9. These deletions have been shown to occurat a similarincidenceof 10-15% in Ph-positiveALL as in CML (Robinsonet al., 2005). In ALL, the t(9;22) occurs at a higher incidence in adults (25-3070) than children (approximately2%), increasing exponentiallywith age (Secker-Walker,1997). Patients tend to have a high WBC count and a high incidence of organomegaly and CNS involvement. The immunophenotypeis typically that of pre-B ALL, although myeloid antigensmay be expressed.In all age groups,the outcomeis extremelypoor despitehighdose intensifiedchemotherapyregimens.Althoughdeletionsof ABLI-BCRwereassociated with a worse outcome in CML, in ALL this association is unclear,due to the already

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extremelypooroutcomeof Ph-positiveALL. Allogeneic transplant,with limited success, providesthe only curativetreatment.Tyrosinekinase inhibitorshave been identifiedwhich selectively inhibit the tyrosine kinase of ABLl suppressinggrowth of the BCR-ABLIpositive cells, and imatinibhas shown success in the achievementof hematologicaland molecularremissionin CML. Trialsare beginningto show similarpromisein childhood ALL, in which imatinibgiven in combinationwith intensivechemotherapyhasresultedin a significant improvementin event-free survival. Longer observationwill be requiredto determinewhetherthis resultsin a differencein long-termsurvival(Schultzet al., 2007a).

t(10;l l)(pl2;q14) The t( 10;11) fuses the MLLTIOgene at lop12 with PlCALM(phosphatidylinositol binding clathrin assembly protein, previously known as CALM) at I Iq14, giving rise to the PICALM-MLLTIOfusion gene (GroupeFrancaisde CytogenetiqueHematologique,199I ; Dreylinget al., 1998). It representsone of the T-ALL specific abnormalitieswhich impair cellulardifferentiation(De Keersmaeckeret al., 2005b). MLLTIOis also the partnerof the MLLgene in complex rearrangements between lop12 and I lq23 (see below). Distinction between the two translocationscan be difficult and HSH or RT-PCR analysis is often as expression required.ThePICALM-MLLTI0 fusionmay occurin a crypticrearrangement has been shownin the absenceof the translocation(Asnafiet al., 2003). Expressionarrays haveshownthatT-ALLexpressingthe PICALM-MLLTIOtranscript hada distinctiveprofile with associated upregulationof HOXAS, HOXA9, and HOXAIO and their coregulator MEZSI (Meis homeobox-1)(Dik et al., 2005). The t(lQ11) is a rare abnormality,in line with the knowledge that chromosomal rearrangementsarising from the in-frame fusion of genes are generally uncommon in T-ALL.It was initiallydescribedin immatureT-ALL(GroupeFrancaisde Cytogenetique Hematologique,1991) and confirmed more recently to occur in approximately10%of childhoodandadultT-ALL(Asnafiet al., 2003). Thereare also reportsof this translocation in lymphomasandacuteleukemiasof severallineages.InT-ALL,it is associatedwith a poor prognosis,althoughthis has been shown to be dependenton the stage of maturationarrest (Asnafiet al., 2003).

Rearrangements Between 1Opl2 and 11q23 In theserearrangements, the MLLTIOgene recombineswithMLLto formtheMLLTlO-MLL fusion. In contrastto the othergenes recombiningwith MLL, MLLTZOis orientatedin the oppositetranscriptional direction,thusit is not possible to generatethe 5’ MLL-3’ MUTf 0 fusion from a simple reciprocaltranslocation(Beverloo et al., 1995). An in-framefusion requiresa more complex mechanismof rearrangement.This explains why some cases, whichappearto involvea morecentromericbreakpointon chromosome1 1 ( I lql2-14), still rearrangethe MLL gene at I lq23. Such cases involve a three-breakrearrangementwith inversion of 1 Iq and translocationof the inverted segment into lop. This results in the juxtapositionof 5’ MLL with 3‘ MLLTIO, which then becomes fused in the correct orientation(Lillingtonet al., 1998). Alternatively,the fusion may arise from a submicroscopic inversionand insertion(Tanabeet al., 1996). In these complex and insertioncases, FISH or RT-PCR may be requiredto detect the involvementof MLL. The MLL-MLLTIOchimerais principallyfound in AML of M5a FAB type (Chapter5 ) , althougha small numberof ALL cases (comprisingapproximately15% of the total) have

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been reportedin T- and pre-B ALL (Lillington et al., 1998). Due to the small numbers describedin ALL, the prognosticassociationis unknown.

t(l0;14)(q24;qll) The t(10;l4) was first associatedwith T-ALL by Dube et al. (1986). As a result of the translocation,the class I1 homeobox gene TLXl (T-cell leukemiahomeobox I , formerly known as HOXii)at 1Oq24is closely apposedto the promoterelementsof T W R D on chromosome 14, or in rare cases to TRB in the t(7;10)(q34;q24)(see above), and is transcriptinallyactivated to express the full-length protein at a high level (Hatano et al., 199I ;Kennedyet al., I99I). TLXl is not normallyexpressed in developingT-cells, althoughits oncogenicpotentialis well known.TLXl is also frequentlyactivatedin T-ALL in the absence of visible genetic rearrangement(Ferrandoet al., 2002, 2004b; Kees et al., 2003). It is expressed in approximately30% of T-ALL, more often in adult than in childhoodcases. These leukemiasshow an earlycorticalphenotypeand a morefavorable outcome than do otherclasses of T-ALL (Ferrandoet al., 2004b).

t(ll;14)(p13;qll)/t(l1 ;14)(p15;qll) Thesetranslocationsarefoundin T-ALL.The LIM-domain-onlygenes LMOIandLM02 in 1 lp15 and I lp13, respectively, are involved in the t(l1;14)(p15;qlI ) and t(l1;14) (pl3;qlI), juxtaposingLMOl and L M 0 2 , respectively,to the T W R D locus (McGuire et al., 1989; Royer-Pokoraet al., 1991). Translocationswith TRB have also been reported (Cauwelieret al., 2006) (see t(7;l l)(q34;p13)/t(7;1 l)(q34;p13) above) (Rabbitts,1998). These rearrangements result in overexpressionof LMOI/LM02. Cryptic deletions of the short arm of chromosome 1 I, del( I l)(p12p13), have been identifiedin 4% of pediatricT-ALL by aCGH(van Vlierbergheet al., 2006). They lead to activationof the LM02 oncogeneby deletionof the negativeregulatoryelementsupstream of LM02, which normallydownregulateexpressionof the gene. L M 0 2 becomes upregulated by its proximalpromoterin the same manneras it happensin the translocations. Together,these rearrangementsaccount for 9% of pediatricT-ALL. Overall, abnormal expression of LMOI and L M 0 2 occurs in 45% of T-ALL; this includes cases with no evidenceof chromosomalchanges(Ferrandoet al., 2002; Asnafi et al., 2004). Deregulation of LMOI/LMO2 often occurs in associationwith deregulationof LYLl ( L M 0 2 ) or TALI (LMOI and LM02), confirmingtheir involvementwithin common oncogenic pathways. LMOl/TALl deregulationis morefrequentin T-ALLcommittedto the alphaheta-lineage. LM02, when coexpressedwith LYLl ,predominantlyoccursin immatureT-ALLin adults, in which the cells arecommittedto no particularcell lineage.The prognosticassociationis unclear.

The t( I I ;19) is one of the morefrequentlyoccurringM U trgnslocations.The breakpointon chromosome 19 may involve 19~13.1or 19~13.3,more easily detected by G- and Rbanding,respectively(Huretet al., 1993).These alternativebreakpointsare the sites of the ELL (elongationfactorRNA polymerase11, previouslyknownas ELLl) and MLLTl genes, respectively,which recombinewith MLL formingthe MLL-ELL andMLL-MLLTlO fusion

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genes, respectively(Yamamotoet al., 1993;Thirmanet al., 1994).The t( I 1 ;19)(q23;p13.1) has only been found in AML, thus the readeris referredto Chapter5 for details. The t( I 1 ;19)(q23;p13.3) occursin both AML andALL, althoughthe majorityarepre-B and T-ALL. In both diseases, it is frequentlyaccompaniedby secondarychromosomal changes,most often gain of an X chromosomeandtrisomy8 (Moormanet al., 1998). This translocationpredominatesin youngerpatients,particularlyinfants.As for the otherM U rearrangements,the leukemiais associatedwith a high WBC count, organomegaly,and early leukemic involvement of the CNS. The survival in these ALL patients is poor, remainingunchangedby the presenceof additionalcytogeneticabnormalities(Moorman et al., 2005).

t(l2;14)(pl3;qll) Ln T-ALL with the rare recurrenttranslocationt(12;14)(p13;qlI ) (see also t(7;12) (q34;p13.3) above), upregulationof CCND2 is broughton by translocationto TRA. To investigatethe expressionof othergenes in I2p13, gene expressionprofilingwas performed comparing expression data for eight genes, including CCND2, surroundingthe I2p breakpointwith those in other T-ALL cases. The t( 12;14)-positiveT-ALL displayed an increasedexpressionof CCND2 comparedto the controls,whereasthe expressionof the othergenes was similarin all T-ALLcases. The t( 12;14)was the firstneoplasia-associated translocationshown to result in overexpressionof cyclin D2. Furthermore,it is the first exampleof a T-cell neoplasmwith a targetedderegulationof a memberof a cyclin-encoding gene family (Kanmanet al., 2006a). t(l2;17)(pl3;qll) The t( 12;I7)(pl3;qll) is rarein ALL. It involves the zNF384 gene (zinc fingerprotein384, previouslyknownas CIZandNMP4) in 12p13,distalto ETV6, andthe TAFl.5 gene in 17q1 1 (Martiniet al., 2002). Two othertranslocationsthatinvolve ZNF384 are t(12;22)(p13;q12) (see below) andthe cryptict( 12;19)(p13;p13)(see below) which rearrangeEWSRl (Ewing sarcomabreakpointI , previouslyknownas EWS) andTCF3 (E2A),respectively.Molecular andcytogeneticanalyseshaveprovidedevidencethatthe translocationsinvolvingZNF384 are primary events, playing an early role in the leukemogenic process (La Starza et al., 2005). These rearrangementscharacterizea specific subset of ALL with an early B-phenotype,myeloidmarkerexpression(CD13andorCD33), no bulkydisease,andonset in young adults(medianage 22 years).As numbersare small, prognosticassociationsare difficult, althoughcurrentdata suggest an overall relativelyfavorableoutcome.

t(12;19)(p13;pl3) The t( 12;19) has so far been reportedin only three cases of B-lineage ALL (La Starza et al., 2005; Barberet al., 2007; Zhonget al., 2008) butis of interestas it recombinesTCF3 at 1 9 ~ 1 3with the ZNF384 gene at 12~13.The TCF3 gene is known for its involvementin t(1;19)(q23;p13)(see above) and the variant, t(17;19)(q22;p13)(see below). Thus, the t( 12;19)likely representsanotherraret( I ;19) variantin whichZNF384 emergesas the third transcriptionfactorto be involved in TCF3 fusions in ALL. ZNF384 is also the partnerin other translocations,namely t( 12;17)(p13;qlI ) (see above) and t( 12;22)(p13;q12)(see

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below). The t( 12;19) results in two fusion genes, TCF3-ZNF384 on the der(19)t(12;19) andNOW-TCF3 (NOLI-nucleolarprotein I ) on the der(I2)t(12;I9), involvingduplication of material from 12p (Zhong et al., 2008). The clinical associations and outcome are unknown.

t(l2;21)(p13;q22) The t(12;21) was firstdiscoveredby FISH in 1994 (Romanaet al., 1994). It is invisibleby conventionalcytogenetic analysis as the bandingpatternand the size of the translocated regionsbetweenchromosomes12 and21 areidentical.The translocationinvolves the ETSETS leukemiagene) at type variant6 (ETV6) gene (previouslyknown as TEL-translocated 12pl3andthe RUNXI gene (runt-related transcriptionfactor1, previouslyknownasAMLlacutemyeloid leukemia1, or CBFA2) at 2 lq22, which recombineto forman ETV6-RUNXI fusiongene on the derivedchromosome2 1 (Golubet al., 1995;Romanaet al., 1995a).It has been convincinglydemonstratedthatthe formationof ETV6-RUNXl fusion is a prenatal event. Evidencefor this came fromthe findingof the sameE W 6 clonogeneicbreakpointin monozygotictwins who bothdevelopedETV6-RUhXI positive ALL atdifferenttimes, and the finding of the fusion in neonatal blood spots of children who later developed ETV6RUNXI positive ALL (Fordet al., 1998; Greaveset al., 2003). Althoughrarevariantbreakpointshave been identified,RT-PCRusingprimersforexon 5 of ETV6 and exon 3 of RUNXI detectsthepresenceof the ETV6-RUNXl fusiontranscriptat the mRNA level in the vast majorityof cases. FISHanalysisusing probesspecific to ETV6 and RUNXI enablesthe ETV6-RUNXI fusion to be accuratelyvisualizedin interphaseand metaphasecells. At the same time, the FISH signal patternindicatesthe presenceof EW6 deletionsfromthe chromosome12homologuenot involvedin the translocationandthegain of copies of the normal or derived chromosome21. All three abnormalitiesare frequent secondary changes that accompany the t(l2;21) (Raynaud et al., 1999; Attarbaschi et al., 2004). In particular,the deletionof ETV6 has been describedas an essentialsecond hit afterthe t(12;21) has provideda preleukemicfirstevent (Greaves,2000). The extentof the deletion can be highly variable, ranging from cytogenetically visible deletions to intragenicdeletions of ETV6 (Raynaudet al., 1996a). It has been shown that the fusion positive cell populationmay be highly heterogeneous,differingin the numbersof RUNXI signals and in the retentionor loss of the second E W 6 signal, while the numberof fusion signalsis moreconstant(Martineauet al., 2005). It has also been shown thatnear-triploidy and near-tetraploidyin childhood BCP-ALL are highly characteristicof EW6-RUNXIpositive leukemia (Attarbaschiet al., 2006; Raimondiet al., 2006), and that deletionsof 1 lq23 are frequentsecondarychanges (Attarbaschiet al., 2007). A numberof RT-PCR and FISH-basedstudies have shown t(12;21) to be the most common translocationin childhood ALL, occurringin 25-30% of pre-B/commonALL (CDIOand HLA-DR positive) with a peak in the age of 3-5 years (Romanaet al., 1995b; Shurtleffet al., 1995; McLeanet al., 1996; Borkhardtet al., 1997; Harrisonet al., 2005). Althoughnot exclusively restrictedto children,the incidence in adultALL is low ( 1 4 % ) (Aguiaret al., 1996; Raynaudet al., 1996b; Kwong and Wong, 1997; JabberAl-Obaidi et al., 2002). Theoutlookforchildrenwith ALL andthis abnormalityis generallyvery good (Shurtleff et al., 1995), althoughthere are indicationsthat it may be associatedwith a late relapse (Harbottet al., 1997;Forestieret al., 2008b). It is possiblethatthe additionalchromosomal changes,the extentof the E W 6 deletion,and the size of the leukemiccell populationmay

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play a role in determiningthe likelihoodand timing of relapse (Martineauet al., 2005). A study of the moleculargenetic analysis of relapse suggested that the initial and relapse clones representdifferentsubclonesthat evolved from a common EW6-RUNXI-positive, treatment-resistant precursor.Matchinggenomic EW6-RUNXZbreakpointsof the initial and the relapseclones in these patientsconfirmedtheir origin from a common progenitor cell. Retrospectiveanalysisrevealedthatthe relapseclone was alreadypresentatdiagnosis, with a much slowerresponseto therapycomparedwith the dominantleukemicclone. In all instances,these initiallyslow-respondingclones, afterthey had developedinto the relapse leukemia, were rapidly eradicatedby the relapse treatment,underliningtheir different biology at the two time pointsof leukemiamanifestation.The authorshypothesizedthatthe minorclone was not fully malignantat initialdiagnosisbut acquiredfurthermutationsfor the manifestationof relapse(Konradet al., 2003).

The t( 12;22) recombinesZNF384 at I2pl3 with EWSRf (Ewing sarcomagene) at 22q12 (Martiniet al., 2002). Fusionsof theTET-proteins(TLS/FUS, EWSR1. andTAFl5/RBP56) to differenttranscriptionfactors are involved in various malignanciesincludingEwing sarcoma,primitiveneuroectodermaltumors,and AML. These arethoughtto arisethrough transcriptional deregulation,with the transcriptionfactordefiningthe tumorphenotype.As aresultof a t(12;17)(p13;qlI)oritsvariant t(12;22)(p13;q12),thetranscriptionfactorgene ZNF384 is recurrentlyinvolved in acute leukemia throughfusion with either TAF1.5 or EWSRf , respectively.The fusions possess transformingpropertiesin NIH3T3cells but do not affect the expressionof ZNF384targetgenes, suggestinga contributionto oncogenesis propertiesof the fusion protein.These resultsalso thatis independentof the transactivating extend the involvementof TET-proteinfusions to ALL and suggest a role for ZNF384 in lymphoidand myeloid development(see also t(12;17)(p13;qll)and t(12;19)(p13;p13)).

Approximately2% of childhoodand adult B-lineage ALL have abnormalitiesinvolving 13q12- 14. Interstitialdeletionsarethe most frequent,althougha numberof translocations associated with 13q loss have also been described.The centromericdeletionbreakpointis typically in the 13q12-14 region, and the telomeric one between 13q21 and 13qter. Although it occurs as the sole karyotypicabnormalityin approximately10%of cases, it is regardedas a frequentsecondaryevent (Kovacset al.. 2004). ALL with abnormalitiesof 13ql2-14 tendsto be associatedwith particularlypoor risk clinical features.For example, childrenare more likely to be infants or greaterthan I0 years old. In one report, 13q aberrationswere associatedwith reducedevent-freesurvival(Heeremaet al., 2000a). The observationthat the incidence of chromosome 13 deletions was higher at relapse led to the suggestionthatdel( I3q) may conferan increasedriskof treatmentfailure.However,to date it has not been shown to be an independentprognosticindicator.

inv(l4)(qllq32)/t(14;14)(qll;q32) The t( 14;14) and inv( 14) recombine TRA at 14qll with the TCLI (T-cell leukemia 1) oncogene at 14q32.I , centromericof the IGH locus (Croceet al., 1985). Rarelythe TRB

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locus is alternativelyinvolved in the t(7;14)(q35;q32).TCLl is upregulatedby the control elementsof the TCR gene whetherthey arepositioned5’ of TCLI,as fortranslocations,or 3’ as for inversions.A similar situationhas been observedin BurkittIymphomaAeukemia, wherethe immunoglobulinenhancerscan be locatedeitherupstreamor downstreamof the MYC oncogene (Chapter10). The abnormalitiest( 14;14) and inv( 14) have been detectedat high frequencyin ataxia telangiectasia(AT), being seen in 7-10% of all AT cases, and in all types of T-lineage lymphoidneoplasias;the t( 14;14)/inv(14) is consideredto be a characteristicchromosomal aberrationin T-cell leukemiasecondaryto AT (Mengle-Gawet al., 1988), associatedwith postthymictypes of T-ALL such as T-prolymphocyticleukemia (T-PLL) and acute or chronicT-cell leukemia.TCLl is overexpressedin the majorityof cases of T-PLL.In vitro, TCLl can modulatethe activityof the serine-ihreoninekinase AKT, a downstreameffector of TCR signaling.It has been shown thatthe expressionof TCR, high levels of TCLl, and activated AKT are adverse prognostic markersin T-PLL. High-level TCLl in TCRexpressing T-PLL is associated with higher presentingWBC counts, faster tumor cell doubling,and enhancedin vitro growth(Herlinget al., 2008). A rarely occurring inv(14)(q1 1.2q32.3I ) has also been reported,which results in expression of the BCLl IB-TRD fusion in association with the absence of the wild-type BCLIIB transcript(Przybylskiet al., 2005) (see section above on t(5;14)). This translocation is indistinguishablefrom the inv( 14) involving TCLl. A small numberof cases have been describedwith t( 14;14) or inv( 14) in BCP-ALL(Liu et al., 2004; Akasakaet al., 2007). These abnormalitiesare significantas they represent anotherrearrangement involvingZGHand a memberof the CEBPgene family,in this case CEBPE. Expressionof this gene is upregulatedas describedfor the otherIGH translocations, namely t(8;I4)(q 1 1 ;q32) (CEBPD) (describedabove), t( 14;19)(q32;q13) (CEBPA and CEBPG), and t(14;20)(q32;q13)(CEBPB) (describedbelow). As for the other ALL subgroupswith translocationsbetween IGH and a memberof the CEPB gene family,they have a pre-Bimmunophenotype,areolderchildrenand adults,and have low WBC counts. The prognosticimpactof these abnormalitiesis currentlyunknown,butthereis no evidence to indicate that the outcome is poor.

t(l4;18)(q32;q21) The t( 14;18) is commonin follicle-centerB-cell lymphomas,being foundin approximately 80%of follicular lymphomasand approximately20% of diffuse largeB-cell lymphomas (Chapter10). Around40 cases with this translocationhave been describedin B-lineage ALL, with the first ones reported25 years ago (Mufti et al., 1983). The t(14;18) is often associatedwith otherchromosomalabnormalities,particularlywith t(8; 14)(q24;q32)and its variantst(2;8)@12;q24)and t( 14;22)(q24;qI I) (reviewed by D’Achille et al., 2006). ALL with t( 14;18) is eitherpre-Bor matureB-ALL,andthe medianage of the patientsis 43 years.It hasbeen suggestedthatt( 14;18)in ALL may ariseas a blastictransformationof a preceding undetectedlymphoma,althoughlittle evidence exists for this. These patients have an extremelypoor outcome in terms of event-freeand overall survival.

t(l4;19)(q32;ql3) The t( 14;19) has been reportedin patientswith chroniclymphocyticleukemia(CLL)and lymphomain which IGH is recombinedwith BCW (Chapter10). In BCP-ALL,the same

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translocationhas been describedinvolvinglGHand CEBPA (Robinsonet al., 2004; Chapiro et al., 2006; Akasakaet al., 2007). The lattergene is one of the CEBP proteinsthat are a family of six multifunctionalbasic leucine zipper (bZIP) transcriptionfactors.CEBPA is overexpressedas a resultof the t( 14;19), implicatingits role as an oncogene in BCP-ALL. CEBPA is known to be mutatedin AML, in which it operatesas a tumorsuppressorgene. Thus, CEBPA demonstratesopposing functionsof CEBP dysregulationin myeloid and lymphoidleukemogenesis(Akasakaet al., 2007). In one ALL with the same translocation,the IGH partnerwas found to be CEBPG, another CEBP family member located 71 kb upstreamof CEBPA in 19q13 (Akasaka et al., 2007). As notedfor thet(8;14)(qI 1;q32),the t( 14;19) involvingCEBPG was shownto be secondaryto t(9;22)(q34;qll)(Akasakaet al., 2007). Three other CEBP gene family membershave been describedas IGH partnersin the t(8;14)(ql l;q32) (CEBPD)(described above), inv(l4)(ql Iq32)/t(14;14)(qll;q32) (CEBPE), and t(14;20)(q32;q13) (CEBPB) (describedbelow). As for t(8;14)(q11;q32), all t( 14;19)-positiveALLhavea pre-Bimmunophenotype.The patientstendto be olderchildren(medianage I5 years)andadults,andthe WBC countsare usually low. The prognostic impact of abnormalitiesinvolving the CEBP family is unknown,but there is no evidence to indicatethat the outcome is particularlypoor.

t(l4;20)(q32;qi 3) Althoughonly four B-lineage ALL cases with the t( 14;20) have been reported,it is worthy of note as it representsanothertranslocationformed between IGH and a memberof the CEBP gene family, CEBPB. CEBPB expressionis upregulatedas describedfor the other IGH translocationsdescribedabove:t(8;14)(ql I ;q32) (CEBPD), inv( 14)(qI lq32)/t(14;14) (q 1 l;q32) (CEBPE), and t( 14;29)(q32;q13)(CEBPA and CEBPG).

t(14;21)(ql1 ;q22) OLlG2 (oligodendrocyte lineage transcriptionfactor 2, also known as bHLHBI) is upregulatedin T-ALLby the raretranslocationt( 14;21)(ql l;q22), whichjuxtaposesOLIG2 and TRA (Wanget al., 2000). Sequenceanalysisof the genomic breakpointsindicatedthat the translocationhad been mediatedby an illegitimate V(D)J recombinationevent that disruptedTRA and relocatedits enhancerelementsto the derivative2 I chromosome,close to OWG2. This gene maps to the region of chromosome21 that has been proposedto be responsible, at least in part, for the learning difficulties seen in children with Down syndrome. Although OWG2 expression is normally restrictedto neural tissues, T-cell lymphoblastswith the t( 14;21)(ql1.2;q22) also express high levels of OLIG2 mRNA. Expressionof OLIG2dramaticallyinhibitsE2A-mediatedtranscriptionactivationin MH 3T3 fibroblastsand JurkatT-cells, suggestingthat OLIG2, similarto TALI, may exert a leukemogeniceffect througha functionalinactivationof E2A or relatedproteins.

15ql3-15 Rearrangements In childhoodALL, abnormalitieswith breakpointsin chromosomebands 15ql3-I5 have been reportedat an incidenceof I % (23 cases were reviewedby Heeremaet al., 2002). Of particularnote was that the majoritywere balanced translocationsinvolving a range of

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chromosomalpartners.The findings indicate that genes within this chromosomalregion may play a role in leukemogenesis.Additional chromosomalabnormalitieswithin the karyotypes,involving chromosomesotherthan 15, includeabnormalitiesof 12p and9p or t(9;22)(q34;qll).The majorityof cases have been B-lineageALL with only a single case of T-ALLreported.Most patientshad standardrisk ALL, with the exceptionof those with t(9;22), althoughthey were more frequentlyinfantsthan older children.The outcomeof patientswith 15qabnormalitieswas not differentfrompatientswithoutthem;therefore,this abnormalitydoes not appear to confer an increased risk of treatmentfailure, unless associatedwith t(9;22).

i(l7)(ql 0) Althoughthis aberrationhas been describedin more than 100 cases of ALL, it was the sole anomalyin only a handful.It is, togetherwith i(7)(q10) and i(9)(qlO),the most common isochromosomein ALL (Pui et al., 1992; Mertenset al., 1994). The overall occurrenceof i( 17)(q10) as a secondarychromosomalabnormalityis particularlycommonin leukemias with t(9;22) as the primaryaberration(especially in CML;see Chapter7). However, it is relatively frequentlyfound in high-hyperdiploidALL, sometimes as the only structural rearrangement. In a few cases, it has been seen in associationwith otherprimarychanges, such as t(4;l l)(q21;q23) and t(8;14)(ql l;q32). Therefore, it is not surprisingthat the clinicalandhematologiccharacteristicsof ALL with i( 17)(q10)do not differmarkedlyfrom those of other cytogenetic subtypes(Pui et al., 1992). The molecularconsequencesof i(17)(q10)remainunknown.Oneeffect is the loss of one allele of eachgene on 17p,includingthe TP53(tumorproteinp53, previouslyknownasp53) tumor suppressorgene, as seen in AML with complex karyotypes(Chapter5). As the frequency of TP53 mutations is low in childhood lymphoid malignancies (Wada et al., 1993), it is possible that loci other than TP53 are the targetof this abnormality.

t(17;19)(q22;pl3) The t(17;19) is a raretranslocation,with fully reportedkaryotypesin only I0 cases in the literature.It is a significantvariantoft(1;19)(q23;p13) (see above).The leukemiccells with t(17;19) producea chimerictranscriptresultingfromthe fusion of TCF3 at 1 9 ~ 1 with 3 the hepaticleukemiafactorgene HLF at 17q22(Inabaet al., 1992).HLF is a basicleucinezipper @ZIP) transcriptionfactor,andtwo main typesof genomicrearrangement enablethe fusion of TCF3 with HLF, correspondingto slightly differentbreakpointpositions (reviewedin arise from a breakpointwithin intron 13 of Hungeret al., 1994). Type I rearrangements TCF3 andintron3 of HLF, while type I1 rearrangements involve a breakpointwithinintron 12 of TCF3 and intron 3 of HLF. Both types generate novel chimeric proteins with transcriptionregulatingability. As for t( 1 ;19), ALL with t( 17;19) has a pre-B immunophenotype.Type I molecular rearrangementshave been suggested to be associated with disseminatedintravascular coagulation(DIC)andtypeI1 with hypercalcemia.All patientshave had a highWBCcount at diagnosis.The prognosisassociatedwith this translocation.%emsto be extremelypoor, with all reportedpatientshaving died (Hunger,1996). Anotherrarelyoccurringcrypticrearrangement of TCF3has also been reportedin three cases; a t (12;19)(p13;p13)thatresultsin the formationof two differentfusion genes on the derivativechromosomes(see above).

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iPl)(qlO) Isochromosome2 I q is rarein ALL, with 3 1 of the 52 reportedcases havingbeen described in only two publications(Martineauet al., 1996; Cooley et al., 2007). This abnormalityis associatedwith the ETV6-RUNXI fusion;thus,the findingof an i(2 1 )(q 10)by cytogenetics alone does not indicatewhetherthe abnormalchromosomeis i(2 I)(q lo) or ider(2l)(q 10) t( 12;21)(p13;q22).If, duringcytogeneticanalysis,i(21)(qIO)is foundas the sole change,it is recommendedto searchfor thepresenceof the MV6-RUNXI fusionby FISHor RT-PCR, as previously suggested when trisomy 21 is found as the sole cytogenetic abnormality (Kanmanet al., 2006b). The clinical and prognosticassociationsof i(21)(qIO)in ALL are unclear.Among the 15 cases describedby Martineauet al. (1996), the patientscharacteristically had a low WBC countand the ALL cases displayeda B-lineage immunophenotype. The largestudyby Cooley et al. (2007) presenteda survivalanalysisof i(2 l)(qlO) together with otherALL patientsharboringabnormalitiesof 21q. The poorprognosisaffordedto the amplificagroupas a whole may be due to the presenceof patientswith interchromosomal tion of chromosome21 (iAMP21) among them (see below), while those with a favorable outcome may harborthe ETV6-RUNXI fusion. lntrachromosomalAmplification of Chromosome 21 (iAMP21) This abnormalitywas firstdescribedas multiplecopies of the R U M 1 gene on an abnormal chromosome21 (Busson-LeConiatet al., 2001). No pointmutationsweredetectedin exons 3-5, encodingthe runtdomainof RUNXI, thussuggestingan oncogenic role for wild-type R U M , or the involvementof othergenes from within the amplifiedregion as the targetof this abnormality.Two later series described a significant numberof patients with this abnormality(Harewood et al., 2003; Soulier et al., 2003). In the majority of cases, amplificationof the RUNXJ gene was detectedduringroutinescreeningfor the presence of the ETV6-RUNXI gene rearrangementby interphaseFISH (Harrisonet al., 2005). It manifestsas multiple copies of the RUNXI gene, which are seen as clustersof signals in interphasecells andin tandemduplicationalong the long arm of an abnormalchromosome 21 at metaphase. Array CGH and FISH studies have defined a minimal region of amplification6.6Mb in size in all cases. This region always includes RUNXI, frequently in association with loss of 21q subtelomericsequences (Streffordet al., 2006; Robinson et al., 2007). Gene expression profiling studies showed no significant differentially expressedgenes to distinguishiAMP2I patientsfrom otherALL patientswith abnormalities of chromosome2 I , includingthose with ETV6-RUNXI fusion andhigh hyperdiploidy with two or more extracopies of chromosome2 I (Streffordet al., 2006). The expression levels of RUNXI were highly variable,reflectingthe expressionof thisgene in ALLsamples in general.Thus,thereis no indicationthatR U M 1 is thetargetgene of thisabnormality.The abnormalchromosometakes on a surprisingvarietyof morphologicalformswhen examined by cytogenetics (Fig. 9.5), metaphaseFISH, and multiplecolor bandingtechniques. These observationsindicatethatthe abnormalchromosome2 I arisesfromhighly complex intrachromosomalrearrangements, includinginversions,duplications,and deletions.This led to the proposal that such a high-level chromosomalinstability had arisen from a breakage-fusion-bridge cycle (Robinsonet al., 2007). The abnormalityhas subsequently been more appropriatelyrenamedas intrachromosomal amplificationof chromosome21 (iAMP21 ). It is defined by the presenceof threeor more additionalcopies of RUNXI on a single abnormalchromosome2 1 with frequentdeletion (or displacement)of subtelomeric

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FZGURE 9.5 Partialkaryogramsfrom five patientswith iAMP2 1. Thenormalchromosome2 1 is on the left and the dup(2I ) is on the right.The variablemorphologyandG-bandingpatternare shown.

21q sequences.The 21q amplificationis not associatedwith ETV6-RUNXI fusion or with any otherestablishedchromosomalchange, includinghigh hyperdiploidy.Karyotypesare pseudodiploidor low hyperdiploid,with gain of the X chromosomeas the only recurrent secondarychangefound in 22% of patients.FISHwith probesdirectedto the R U M / gene remainsthe only reliabledetection method for this abnormality.In cases without metaphases,additionalprobesshouldbe appliedto distinguishiAMP2l fromhigh hyperdiploidy with additionalcopies of chromosome2 1. These might include a subtelomericprobe to chromosome21, to demonstratethat the numberof RUNXI signals is greaterthan the numberof chromosomes2 1, and centromericprobesspecific for the otherchromosomes (otherthan the X), which are usually gained in high hyperdiploidy. ALL with iAMP21 has characteristicclinical features.It is foundamongan oldergroup of childrenor adolescents (median 9.4 years, range 3-20 years) with a commodpre-B immunophenotypeat an incidenceof approximately2% in childhoodALL. The patients generallyhave a low WBC count as comparedto patientswithoutthe abnormality.The association of the amplification with a poor prognosis was a very significant finding (Robinsonet al., 2003). In the United KingdomchildhoodALL treatmenttrial, ALL97, the 5-year EFS for patients with the amplificationwas 26% comparedto 83%for those withoutthis abnormality.As a result of these findings, althoughas yet unpublished,UK patientshave been transferredto an intensive treatmentregimen in the currenttreatment trial, ALL2003. At the time of writing, with a median follow-up of 4 years, although approximately30 iAMP21 patientshave been treatedon this trial, there have been no reportedrelapses. Thus, the treatmentdecision appearsto have been correct,certainlyin relationto the early relapse.

SECONDARY CHROMOSOMAL CHANGES In ALL, the secondarychromosomalchanges,as the primaryrearrangements, are nonrandom. The type of secondaryaberrationsvaries dependingon the natureof the primary abnormality.Severalof the abnormalities,bothstructuralandnumerical,thatarerelevantin the context of clonal evolutionhave alreadybeen discussedin the relevantsections. A picture of the cytogenetics of clonal evolution is provided by examination of metaphasesat relapse. Almost always, the karyotypeis either the same as it was at diagnosis or one or more secondarychanges have been added.Occasionally,however,a

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majorshift is seen, with the relapsekaryotypebeingcytogeneticallyunrelatedto the original one. Raimondiet id. ( 1993)describedninecases with differentkaryotypesandofferedsome explanationsfor thesefindings.Onepossibilityis thatthe new stemlinewas alreadypresent in leukemicor preleukemiccells at diagnosis.but for some reasonit remainedundetectedat that time. Another more probable explanationis that the “relapse”may actually be a secondary ALL broughtabout by the severely genotoxic treatmentthese patients were given.

CLINICAL CORRELATIONS Cytogeneticanalysis plays an integral part in the diagnosis of ALL. Certaingenomic rearrangementsare stronglyassociatedwith distinctivehematologic,immunophenotypic, and clinical features,therebyprovidinga meansfor improveddisease subclassification,as discussed in detail above. The abnormalitiesdiffer between B- and T- lineage ALL with differentdistributionsbetweenage groups.In associationwith theseaspects,the diagnostic karyotypeis also an importantprognostic variable. Modern therapeuticregimens have dramaticallyimprovedthe survivalin ALL (Pui et al., 2004). These improvementshave increasedthe need forreliableprognosticindicatorsto ensurethatpatientsareriskstratified to the most appropriatetreatmentprotocol.

CLASSIFICATIONOF ABNORMALITIES ACCORDING TO LINEAGE The main patternsof cytogeneticabnormalities,which arecharacteristicof B-lineage ALL, (excludingmature-B)include changes in ploidy: high hyperdiploidy,near-haploidy,and low hypodiploidy.The majorityof structuralrearrangements comprisein-frametranslocations leadingto the formationof fusiontranscriptswith oncogenicpotential.These include t( I ;I9)(q23;p13.3) andvariants,t(9;22)(q34;qI 1), MLLrearrangements, t( 12;2I )(p 13;q22), andan increasingnumberof patientswith 14932 abnormalitiesinvolvingZGH,as described in detail above. These cytogenetic subgroupshave distinctiveimmunophenotypiccharacteristicsas well as age and prognosticassociations.Accordingto UK datafrom a single childhood ALL treatmenttrial, ALL97, which incorporatedFISH screeningfor the main abnormalities(Harrisonet al., 2005). the relativeincidencesof these changes have been demonstrated(Fig. 9.6). A more detailedbreakdownof the incidences of the individual abnormalitiesaccording to age is given later in this chapter.If patients with a normal karyotype (8%) are included along with those having none of the above established cytogenetic changes ( 1 8%), approximately26% of B-lineage childhood ALL patients have as yet unclassifiedchromosomalabnormalities.With furtherstudiesincludingFTSH, m a y CGH, SNP array, and molecular approaches,it is likely that new cytogenetic subgroupswill emerge from this unclassifiedgroup, to which specific clinical features may be assigned. T-ALLaccountsfor only 10%of childhoodALL (Fig. 9.7). However,the chromosomal changesaredifferent.Visiblecytogeneticchangesareseen in approximately50%of T-ALL patients.Cryptictranslocations,for example t(5;14)(q35;q32)involving TLx3, and deletions of, for example, TALI, may be detectedby FISH using appropriateprobes(van der Burget al., 2004). considerablyincreasinglythe abnormalitydetectionrate.Translocations involving the T-cell receptorloci are found in approximately35% of T-ALL by FISH

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Poor risk cytogenetics

ETVG-RUNX 1

70,

No established

31yo

Normal 8%

FIGURE 9.6 Pie chart illustratingthe relative incidences of the significant chromosomal abnormalitiesin the childhoodALL treatmenttrial, ALL97. Poor risk cytogenetics:t(9;22)(q34;qlI), 1 lq23/MLL. translocations,near-haploidy/lowhypodiploidy(<40 chromosomes),t( 17; 19)(q22;pl3). Othertranslocations:t( 1;19)(q23;p13), 14q3UIGH translocations.Providedby Dr. AnthonyMoorman.

(Cauwelier et al., 2006). They may result in oncogenes becoming juxtaposed to the promoterand enhancerelements of the TCR genes, leading to their aberrantexpression and the developmentof T-ALL. Alternatively,aberrantexpressionof oncogenic transcription factors in T-ALL may result from loss of the upstreamtranscriptionalelements that normally downregulate the expression of these oncogenes during T-cell development (Ferrandoet al., 2004a). The formationof oncogenic fusion transcriptsis rare in T-ALL. Translocationsof this type include MLL fusions and PICALM-MLLTIO as well some rare rearrangementsinvolving the tyrosine kinase gene ABLI. Aberrantexpression of one or more transcriptionfactors is a criticalcomponentof the molecularpathogenesisof T-ALL. These includethe class B basic helix-loop-helix (bHLH)genes TALI, T A U , LYLI, OWG2, 100%

v)

80%

B

60%

Normal Other T-ALL t(l4q32) g3 iAMP21 Ei t(9;22) t( 11q23)

C

.-r 8 40% 0

2

n 20%

w t(l2;21) 0% Age (years)

FIGURE 9.7 Bar chartshowingthe relativeincidencesof the significantchromosomalabnormali-

ties accordingto age. Data takenfrom UK ALL treatmenttrials.Providedby Dr. AnthonyMoorman.

AGE ASSOCIATIONS

273

and MYC, as well as genes involved in transcriptionregulation,for examplethe cysteinerich LIM-only domain LMOI and LM02 genes. Abnormalitiesalso affect the homeodomaingenes TLXl and TLX3 and membersof the HOXA cluster.Mutations,particularly those involvingNOTCHI, are significantin T-ALL,being found in approximately50%of cases. De Keersmaeckeret al. (2005b) classified the differentT-ALL specific abnormalities into subgroupsthat defined four pathwaysbased on differentclasses of mutations that: ( 1 ) provide a proliferative advantage; (2) impair differentiation and survival; (3) affect the cell cycle; and (4) provide self renewal capacity. One interestingfinding has been the strong interrelationshipsbetween the different types of abnormalitiesin T-ALL. The T-ALL specific oncogenes may be upregulatedby association with the promoterregions of either T W D or TR5, as well as othergenes, for example5CLl IS (and CDK6). In addition to these abnormalities,NOTCH1 mutations and deletions of CDKN2A may be present, indicating an interactingrole for chromosomal abnormalities in T-ALL (Harrison,2007). Interlacedwith these four major classes of mutations is the molecularclassification which has emerged from gene expression profiling (Ferrando et al., 2002; Ferrando and Look, 2003). It has identified several gene expression signaturesindicative of arrestat specific stages of thymocyte development; a LYLl -positive signature represents immature thymocytes (pro-T). TLX1-positivity representsearly cortical thymocytes, and TALI-positivitycorrelates with late cortical thymocytes. Thus, gene expression profiling has improved our understandingof the biological heterogeneity of the disease, while revealing clinically relevant subtypes. In addition, molecular analysis has shown its capacity to elucidate significant pathways relevant to the future treatment of T-ALL. These findings have indicated that continued genetic analysis in T-ALL is importantto furtherclassify this heterogeneous disease.

AGE ASSOCIATIONS

Infants ALL in infants less than 1 year of age is rare.The biological featuresare differentfrom ALL in older children,with infant ALL having an immatureB-lineage phenotype,lacking CD 10 expression, and havinga high tumorload at presentation(Biondi et al., 2000). At the genetic level, infant ALL is characterizedby a high frequency (approximately 70%)of chromosomalabnormalitiesinvolving 1 lq23 and rearrangementsof the MLL gene (Chen et al., 1993; Cimino et al., 1993; Heeremaet al., 1994; Pieterset al., 2007). indicatinga uniquecytogenetic profileamonginfantALL.The t(4;1 l)(q21 ;q23)accounts for more than 50% of the MLL-positivecases, with the majorityof patients being less than6monthsofage.Thet(ll;19)(q23;pI3.3)(20%), t(9;l l)(p21;q23)(1I%),rearrangements between lop 12 and 1 1 q23 (4%). and the otherMLL translocationsare much less frequent. Overall,event-freesurvivalis considerablyworse for infantsthanforolderchildrenwith ALL (Fersteret al., 1994; Frankelet al., 1997; Reamanet al., 1999; Chessellset al., 2002; Biondi et al., 2006; Hilden et al., 2006). Outcomeamong infantswith ALL is heterogeneous and varies accordingto MLL status,CDlO expression,age at diagnosis,presenting WBC count, CNS involvement,coexpressionof myeloid markers,and early response to

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prednisone,with the presence of an MLL rearrangementand age <6 months being the strongestpredictorsfor pooroutcome(Biondi et al., 2000; Pieterset al., 2007). It has been suggestedthatinfantALL with germ-lineMLL representsa specific subsetthatmay havean improvedprognosis(Chenet al., 1993; Pui et al., 1996; Pieterset al., 2007). Among these M U germ-line cases, the common abnormalitiesseen in older children with ALL are underrepresented. High hyperdiploidyis foundin approximately10%of the patientswith a successful karyotypeand is generallyassociatedwith the same improvedoutcomein this age groupas describedfor olderchildren(Heeremaet al., 1994). TheETV6-RUNXl fusion was absentamongthe relativelysmall numbersof MLL-negativecases screened(Chessells et al., 2002; Pieterset al., 2007), indicatingthatthisis not a significantabnormalityin infant ALL.The incidenceof BCR-ABLI positivecases is also very low, less than I %.Therewerea significantnumberof infantALL with 15q abnormalities(approximately10%)(Heerema et al., 2002) andt(7;12)(q36;pl3)is foundexclusively in infants,althoughmainlyin infant AML.

Older Patients The relative incidences of the main chromosomalabnormalitiesaccording to age are indicatedin Fig. 9.7. In contrastto the high incidenceof MLLrearrangements in infants,the proportionseen in olderchildrenis low, with a gradualrise occurringwith increasingage. Children aged 1-9 years have the highest incidence of high hyperdiploidy and t( 12;2l)(p13;q22)(ForestierandSchmiegelow,2006). The incidenceof high hyperdiploidy dropsto a low level in adolescence,while t( 12;21)completelydisappears,apartfroma few sporadic cases in adulthood.The incidence of the t( 1 ;19)(q23;p13)remains relatively constant throughoutthe age groups. Abnormalitiesinvolving the IGH locus at 14q32 emergein adolescencewith an increasingincidenceseen in youngadults.Theproportionof cases with t(9;22)(q34;qll) increasesexponentiallywith age.

DOWN SYNDROME Childrenwith Down syndromehave a greatlyincreasedriskof developingacute leukemia, including ALL. The prevalence is increased almost 20-fold (Hasle et al., 2000), with Down syndrome patients comprising up to 3% of all childhood ALL. The numberof reportedcases with acquiredkaryotypicabnormalitiesis limited,butthe impressionis that the cytogenetic aberrationscharacterizingALL of Down syndromepatientsdo not differ substantiallyfrom those seen in non-Down syndrome individuals,althoughthe distribution is different. A recent multicenterstudy reviewed the cytogenetic features of 2 15 Down syndromeALLpatientsupto the age of 20 years(Forestieret al., 2008~).Although almost 40% had a normalkaryotype,a significantproportionhad the typical pre-B ALL abnormalities,including high hyperdiploidy (1 I %) and t( 12;21)(p13q22) (lo%), although the incidences of both abnormalitieswere lower than those reportedfor nonDown syndrome ALL. It is probable that the incidence of t(l2;21) is more likely approaching15-1 8% if only molecular/FISH-screenedcases are considered. Of note was that the Down syndrome patientswith t( 12;21)(p13;q22)were older (medianage 6 years)thanthe non-Down syndromepatients(medianage 4.3 years).The Down syndrome cases with high hyperdiploidyshowed the same chromosomalgains as the non-Down

PROGNOSIS

275

syndromepatients,indicatingthatthe same mechanismsare involved in the formationof the karyotype.There was a significant overrepresentationof certain cytogenetic subgroups, for example the gain of an X chromosome (approximately40%, and as a sole chromosomalabnormalityin about20%),the t(8;14)(qlI;q32)leading to upregulationof CEBPD(see above)(3%, accountingfor 24%of all reportedcases with thistranslocation), and deletions of 9p (in 20% of cases as the sole visible cytogenetic abnormality).The t(9;22)(q34;qI I ) was found in approximately1% of the cases.

PROGNOSIS A correlationbetween prognosis and the karyotypeat diagnosisin ALL was firstdemonstratedby Secker-Walker et al. ( 1978)andhas since been documentedby manyresearchers. The cytogenetic picture is informativewith regard to disease outcome, and particular significancehas been attributedto the presenceof specific abnormalities,as detailedin the individualsections above. The firstlarge series analyzed for cytogenetic and prognosticcorrelations wasthe 330 cases of newly diagnosed ALL, 66%with clonal aberrations,investigatedby the Third InternationalWorkshopon Chromosomes in Leukemia (IWCL3, 1983). The results showed that chromosomal abnormalitiesidentified both high-risk and low-risk ALL patients. Virtuallyall studies have agreed that in both children and adults, high-hyperdiploid patients have the best prognosis (Secker-Walkeret al., 1989; Groupe Francais de Cytogenetique Hematologique, 1993; Moorman et al., 20031, as described above. Youngerchildren(aged 1-9 years) farebettercomparedto olderones (aged 10-6 years), as well as those with a higher modal chromosome number (56-67 versus 51-55 chromosomes)(Raimondiet al., 1996; Moormanet al., 2003). The previoussuggestion that the presence of structuralabnormalitiespredictedrelapse (Pui et al., 1989) has not been confirmed(Moormanet al., 2003). Therefore,the conclusion is that they impartno changeon the good outcomeassociatedwith this patientgroup.Anothergroupassociated with a good outlook is children with t( 12;2I)(pl3;q22)-positive ALL (Shurtleff et al., 1995). although there are indications that this translocationmay be associated with late relapse (Harbottet al., 1997; Forestieret al., 2008b). Together,high hyperdiploidy and t(12;21) account for approximately50% of childhood ALL, providing a significantinput to the overall good prognosis of childhood ALL. A large recent study based on more than 6000 children with informativecytogenetic data (aged 1-22 years) with BCP-ALLfrom the Children’sOncology Group(COG)allowed analysisof clinical, biological, and early responsedatapredictiveof event-free survivalin ALL to develop a new classificationsystem and treatmentalgorithm.Fourrisk groups were defined:very high risk (5-yearEFS,45%or below), lowerrisk (5-yearEFS, at least 85%),with high and standardrisk between the two. The very high-risk group included hypodiploidy with fewer than44 chromosomes,t(9;22) andlorBCR-ABLI positivity,and inductionfailure. Lowerrisk patientsincludedthosewith t( I2;2 I ) (ETV6-RUNXl positive) or simultaneous trisomiesof chromosomes4, 10, and 17 to indicatehigh hyperdiploidywith no associated poorrisk clinical features.This COGrisk classificationscheme is being used for division of BCP-ALLinto lower- (27%), standard-(32%),high- (37%). and very high- (4%)risk groups based on age, WBC count, cytogenetic subgroup,day- 14 marrowresponse, and end of inductionminimal residualdisease (MRD) by flow cytometryin COG treatment

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trials(Schultzet al., 2007b). Among patientsin lower risk groups,considerationis being given to the reductionof therapy. The early associationof t( I; 19)(q23;pl3) with a poor outcome has been moderatedby more aggressive therapy in modem protocols (Hunger, 1996). These patients are now consideredas standardrisk on currenttreatmentregimens.On the contrary,the prognosis associated with the variantt( 17;I9)(q22;p13) remainsextremely poor, with all reported patientshaving died (Hunger, 1996). A particularlypoor outcome has been reportedfor children with near-haploidALL (23-29 chromosomes)(Gibbonset al., 1991; Chessells et al., 1997; Harrisonet al., 2004). Patients with low hypodiploidy (33-39 chromosomes)have a similarly poor outcome (Heeremaet al., 1999a;h i et al., 1990; Raimondiet al., 2003; Chamnet al., 2004). The presenceof a duplicatedhyperdiploidhear-triploid populationdoes notchangetheoutcome in either of these hypodiploidgroups. Overallthe outcome for patientswith t(4;l l)(q21;q23)-positiveALL is extremelypoor (Heeremaet a]., 1994;Hannet al., 2001 ;Moormanet a]., 2007a), althoughit is significantly betterin childrenaged 2-9 yearscomparedto infantsand patientsover the age of 10 years includingadults (Johanssonet al., 1998). Although the numberof ALL cases with MLL rearrangements otherthant(4;11) is lower, they are generallyconsideredto have a similar poor outcome in ALL. It has been reportedthatchildhoodpatientswith visible abnormalitiesof 9p have a poor outcome (Heeremaet al., 1999b;Hann et al., 2001), and deletions specifically involving CDKN2A have been associated with a poor outcome in both B- and T-ALL. One report describedthat alterationsin CDKN2B but not CDKN2A are a poor risk factor in adult B-lineageALL (Hoshinoet al., 2002). The most consistentpoor risk associationsare with T-ALL in adults (Yamadaet al., 1997) and children (Fizzotti et al., 1995; Diccianni et al., 1997). However,consideringthe generallypoor prognosisof T-ALL, the addedrisk associatedwith CDKN2A deletionsmightbe questioned.Deletions of CDKN;zA, with and withoutdeletionsof CDKN2B and MTAP, arenot linked to a poor outcomein childhood B-lineage ALL (Mirebeauet al., 2006). The negativecorrelationof CDKN2A inactivation with favorablerisk cytogeneticsubgroupsprovidesa relevantexplanationfor the variable prognosticassociations. ALL with t(9;22)(q34;q1 1) is associatedwith a very poorprognosisin bothchildrenand adults,despitehigh-dose intensifiedchemotherapy.Allogeneic transplantation is the only curativetreatmentfor these patients.The tyrosine kinase inhibitorimatinibhas shown success in the achievementof hematologicaland molecularremissionin CML. Trialsare beginning to show a similarpromise in childhoodALL (Schultzet al., 2007a). The morerecentlydescribedcytogeneticsubgroupiAMP21 is associatedwith a dismal prognosis(Robinsonet al., 2003). The currentestimateof the 5-year EFS for patientswith the amplification was 26% compared with 83% for patients without it (Moorman et al., 2007b). As a result, the currenttreatmenttrial in the UK has transferredthese patientsto moreintensivetreatmentregimens,with considerableimprovementsin outcome. In adult ALL, it has been reportedthat patientswith a complex karyotype,comprising 5 or more unrelatedchromosomal abnormalities,have an extremely poor prognosis (Moormanet al., 2007a). This finding is leading to modificationof treatmentfor these patientsin new adultALL treatmenttrials. In T-ALL,the overall prognosisis generallypoor in comparisonto B-lineage disease. The prognosisof individualcytogeneticgroupsin T-ALL remainsunclearas numbersare relatively small. However,patientsexpressingTLx3 do not sharethe favorableoutcome

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associatedwith TLXlexpression(see above) (Balleriniet al., 2002; Ferrandoet al., 2002; Cave et al., 2004). Additionally,the rare t(10;1i)(p13;qi4) is associated with a poor prognosis in T-ALL, although this has been shown to be dependent on the stage of maturationarrest. The cytogenetic diagnosis is of course not the only prognosticfactorof importancein ALL, and covariation with already established clinical and hematologic parameters includingage, WBC count, percentageof blasts in peripheralblood, immunophenotype, CNS involvement,the presenceor absence of mediastinaltumor,and more recently the presenceof MRD accountsfor some of the observedassociations.The most significantfact is thatthe impactof prognosticfactorsis heavily dependenton the type of therapy,andso a continuousreassessmentof theroleof all prognosticfactors,includingkaryotype,is needed as the consensusof what constitutesstate-of-the-artALL treatmentchanges.

SUMMARY Approximately two-thirds of all ALL cases have established acquired chromosomal abnormalities.Although the aberrationsare quite variable,their distributionis distinctly nonrandom,and some rearrangements are associatedwith hematological,immunophenotypic, and clinical characteristicswith remarkablespecificity.Foran increasingnumberof translocations,the molecularconsequencesare now known. The diagnostic karyotypeis an importantindependentprognosticfactor. With more intensivechemotherapy,however, the adverseprognosticeffect of many ALL-associated chromosomeabnormalitieshas been overcome.The prognosticallymost favorablecytogenetic subgroupsin ALL are being consideredfor therapyreductionand as more rarely occurringpoor risk abnormalitiesare identified, there is promise of targeted therapy identified from the molecularconsequencesof these rearrangements.

ACKNOWLEDGMENTS Financialsupportfrom the LeukaemiaResearch,UK, the Swedish CancerSociety, the Swedish ChildhoodCancerFoundation,and the Swedish ResearchCouncil is gratefully acknowledged.

REFERENCES Aguiar RC, Sohal J. Van Rhee F, Carapeti M, Franklin IM, Goldstone AH, Goldman JM, Cross NC ( 1996): TEL-AMLl fusion in acute lymphoblastic leukaemia of adults. M.R.C. Adult Leukaemia Working Party. Br J Haematol95:673-677. AJtarakaT, BalaqasT, Russell LJ, Sugimoto KJ, Majid A. WalewskaR, Karran EL, Brown DG, Cain K, Harder 1,. Gerk S. Martin-SuberoJI, Atherton MG, Bruggemann M. Calasanz MJ,Davies T, Haas OA, Hagcnieijcr A, Krmpski H, Lessard M, Lillington DM, Moore S, Nguyen-Khac F, RadfordWcias 1, Schoch C. Struski S. Tdley P. Welham MJ. Worley H. StreffordJC, Hamson CJ, Siebert R, Dyer MJ (2007): Five members of the CEBP transcription factor family are targeted by recurrent IGH translocations in B-cell precursor acute lymphoblastic leukemia (BCP-ALL). BIood I09:3451-346 I .

278

ACUTE LYMPHOBLASTIC LEUKEMIA

AsnafiV, Radford-WeissI, DastugueN, Bayle C, Leboeuf D, ChaninC, GarandR, Lafage-Pochitaloff M, Delabesse E, Buzyn A, TroussardX, Maclntyre E (2003): CALM-AFIO is a common fusion transcriptin T-ALL and is specific to the TCRyG lineage. Blood 1 0 2 10W1006. Asnafi V, BeldjordK, LiburM, VillareseP, Millien C. Ballerini P, KuhleinE, Lafage-PochitaloffM, Delabesse E, Bernard0,MaclntyreE (2004): Age-relatedphenotypicandoncogenicdifferencesin T-cell acute lymphoblastic leukemias may reflect thymic atrophy.Blood 104:4173-4 180. AttarbaschiA, Mann G, Konig M, Dworzak MN, Trebo MM, Muhlegger N. GadnerH, Haas OA (2004): Incidence and relevance of secondary chromosome abnormalitiesin childhood TEU AML I + acute lymphoblasticleukemia: an interphaseFISH analysis. Leukemia 18:161 1-1616. AttarbaschiA, Mann G, Konig hrl. Steiner M, Dworzak MN, Gadner H, Haas OA (2006): Neartetraploidyin childhoodB-cell precursoracute lymphoblasticleukemiais a highly specific feature of ETV6RUNXI-positive leukemic cases. Genes Chromosomes Cancer 45:608-6 I1 . AttarbaschiA, MannG, StrehlS, Konig M, SteinerM. JeitlerV, Lion T, DworzakMN, GadnerH, Haas OA (2007): Deletion of 1 lq23 is a highly specifc nonrandomsecondary genetic abnormalityof ETV6RUNXl -rearrangedchildhood acute lymphoblastic leukemia. Leukemia 21 :584-586. BalleriniP. Blake A, Busson-Le ConiatM, Su XU, Zucman-RossiJ, AdamM, van den AkkerJ, Perot J, Douay L, BergerR, BernardOA (2002): HOXI lL2 expression C. PellegrinoB, Landman-Parker defines a clinical subtypeof pediatricT-ALLassociatedwith poor prognosis.Blood 100:991-997. Ballerini P, Busson M, FasolaS, van den AkkerJ, LapillonneH, RomanaSP, MarynenP, BernardOA, Landman-ParkerJ, BergerR (2005): NUP214-ABL 1 amplificationin t(5; 14)/HOX1112-positive ALL present with several forms and may have a prognosticsignificance. Leukemia 19:468-470. Barber KE, Ford AM, Harris RL, HarrisonCJ, Moorman AV (2004a): MLL translocations with concurrent3’ deletions: interpretationof FISH results. Genes Chromosomes Cancer 4 1 :266-271. BarberKE, MartineauM, HarewoodL, StewartM, CameronE, StreffordJC, RutherfordS, Allen TD, Broadfield ZJ, Cheung KL, Harris RL, Jalali GR. Moorman AV, Robinson HM, HarrisonCJ (2004b): Amplification of the ABL gene in T-cell acute lymphoblastic leukemia. Leukemia 18: 1153-1 156. BarberKE, HarrisonCJ, BroadfieldZJ,StewanAR, WrightSL, MartineauM, StreffordJC, Moorman AV (2007): Molecularcytogenetic characterizationof TCF3(E2A)/I 4 1 3 . 3 rearrangementsin Bcell precursoracute lymphoblastic leukemia. Genes Chromosomes Cancer 46:478-486. Bash RO, Hall S, TimmonsCF, CristWM, Amylon M, Smith RG, Baer R (1995): Does activationof the TALI gene occur in a majority of patients with T-cell acute lymphoblastic leukemia? A pediatriconcology group study. Blood 8666-76. BehrendtH, ChamnC, GibbonsB, HarrisonCJ,HawkinsJM,HeeremaNA, Horschler-BotelB, Huret JL; Lai JL, Lampert F (1995): Dicentric (9;12) in acute lymphocytic leukemia and other hematological malignancies: reportfrom a dic(9;12) study group. Leukemia 9: 102-106. Bellido M, AventinA, Lasa A, Estivill C, CarnicerMJ, Pons C. Matias-GuiuX, Bordes R,Baiget M, SierraJ, NomdedeuJF(2003): Id4 is deregulatedby a t(6; 14)(p22;q32)chromosomaltranslocation in a B-cell lineage acute lymphoblastic leukemia. Haemalologica 88:994-1001. Bene MC, Castoldi G, KnappW,Ludwig WD, MatutesE, OrfaoA, Van’t Veer MB (1995): Proposals for the immunologicalclassification of acute leukemias. EuropeanGroupfor the lmmunological Characterizationof Leukemias(EGIL). Leukemia 9: 1783-1 786. BennettJM,CatovskyD, Daniel MT, FlandrinG, GaltonDA, GralnickHR. SultanC (1 976): Proposals for the classificationof the acuteleukaemias.French-American-British(FAB) co-operativegroup. Br J Huematol33:451-458. BergerR, Bemheim A ( I 985): Cytogeneticsof Burkitt’slymphoma-leukaemia:a review. [ARC Sci Pub1 65-80. BergerR, DastugueN, Busson M, van den AJ, PerotC, Ballerini P, HagemeijerA, MichauxL, Chamn C, Pages MP, MugneretF, AndneuxJ, TalmantP, Helias C, Mauvieux L, Lafage-PochitaloffM,

REFERENCES

279

Mozziconacci MJ, Cornillet-LefebvreP, Radford I, Asnafi V, Bilhou-Nabera C, Nguyen KF, LeonardC, SpelemanF, PoppeB, BastardC, TaviauxS, QuilichiniB, HerensC, GregoireMJ,Caw H, Bernard OA (2003): t(5;14)MOXI 112-positive T-cell acute lymphoblastic leukemia. A collaborativestudy of the GroupeFrancaisde CytogenetiqueHematologique(GFCH).Leukemia 17:1851-1857. BergeronJ, ClappierE, CauwelierB, Dastugue N, Millien C, Delabesse E, BeldjordK, Speleman F, Soulier J, MacIntyre E, Asnafi V (2006): HOXA cluster deregulation in T-ALL associated with both a TCRD-HOXA and a CALM-AFIO chromosomal translocation. Leukemia 20:1184-1187. Bernard0,Lecointe N, JonveauxP, SouyriM, MauchauffeM, BergerR, LarsenCJ,Mathieu-MahulD ( 199 I): Two site-specific deletions and t( 1 ;14) translocation restricted to human T-cell acute leukemias disrupt the 5' part of the tal-I gene. Oncogene 6:1477-1488. BernardOA, Busson-LeConiat M, Ballerini P, Mauchauffe M, Della V V, Monni R, Nguyen KF, MercherT, Penard-LacroniqueV, PasturaudP, GressinL, Heilig R, Daniel MT, LessardM, Berger R (2001): A new recurrentand specific cryptic translocation,t(5; 14)(q35;q32),is associated with expression of the Hox 1 I L2 gene in T acute lymphoblastic leukemia. Leukemia 15:1495- 1504. Bertin R, Acquaviva C, Mirebeau D, Guidal-Giroux C, Vilmer E, Cave H (2003): CDKN2A. CDKN2B. and MTAP gene dosage permits precise characterizationof mono- and bi-allelic 9p2 1 deletions in childhood acute lymphoblastic leukemia. Genes Chromosomes Cancer 37:44-57. BeverlooHB, Le ConiatM, WijsmanJ, LillingtonDM, Bernard0,de Klein A, v WeringE, WelbornJ, Young BD, HagemeijerA, BergerR (1995): Breakpointheterogeneityin t( 10;I1) translocationsin AML-M4/M5resultingin fusion of AFlO andMLL is resolved by fluorescentin situ hybridization. Cancer Res 55:4220-4224. Biondi A, Cimino G, PietersR, Pui CH (2000): Biological andtherapeuticaspects of infant leukemia. Blood 96:24-33. Biondi A, RizzariC, Valsecchi MG, De LP, Arico M, Basso G, Locatelli F, Lo NL, De RG, MaseraG (2006): Role of treatmentintensificationin infants with acute lymphoblasticleukemia:results of two consecutive AIEOP studies. Haematologica 91 534-537. BorkhardtA, CazzanigaG, ViehmannS, ValsecchiMG, Ludwig WD, Burci L, Mangioni S, Schrappe M, Riehm H, LampertF, Basso G, MaseraG, HarbottJ, Biondi A (1997): Incidence and clinical relevance of TEL/AMLI fusion genes in childrenwith acute lymphoblasticleukemia enrolled in the German and Italian multicentertherapy trials. Associazione ItalianaEmatologia Oncologia Pediatricaand the Berlin-Frankfurt-Munster Study Group. Blood 9 0 5 7 1-577. Brown L, Cheng JT, Chen Q, Siciliano MJ, Crist W, Buchanan G, Baer RJ (1990): Site-specific recombination of the tal-1 gene is a common occurrencein human T cell leukemia. EMBO J 9:3343-335 1. Brunning RD, Borowitz M, Matutes E, Head D, Flandrin G, Swerdlow SH, Bennett JM (2001): PrecursorB-cell and T-cell neoplasms. In: Jaffe ES, HarrisNL, Stein H, VardimanJW,editors. World Health Organization ClassGcation of Tumours. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. Lyon: IARC Press, pp 109-1 17. BurmeisterT, Gokbuget N, ReinhardtR, RiederH, Hoel7erD, SchwartzS (2006): NUP214-ABL1 in adult T-ALL: the GMALL study group experience. Blood 108:3556-3559. Burnett RC, Thirman MJ, Rowley JD, Diaz MO (1994): Molecular analysis of the T-cell acute lymphoblastic leukemia- associated t( I ;7)(p34;q34) that fuses LCK and TCRB. Blood 84:1232-1236. Busson-Le Coniat M, Nguyen KF, Daniel MT, BernardOA, Berger R (2001): Chromosome 21 abnormalitieswith AML I amplificationin acute lymphoblastic leukemia. Genes Chromosomes Cancer 32:244-249.

280

ACUTE LYMPHOBLASTICLEUKEMIA

ByattSA, CheungKL, LillingtonDM, Mazzullo H, MartineauM, BennettC, RobertsK, HarewoodL, SumptionN, HumphreysM, BurrettJ, HarrisonCJ (2001): Three furthercases of t(8;14)(q 1 1.2; q32) in acute lymphoblastic leukemia. Leukemia 15:1304-1 305. Callen DF, Raphael K, Michael PM, Carson OM (1989): Acute lymphoblastic leukemia with a hypodiploidkaryotypewith less than40 chromosomes:the basis for division into two subgroups. Leukemia3:749-752. Carroll AJ, Crist WM, Parmley RT, Philips C, Krischer J, Head D, Gresik M, RavindranathY, WeinsteinHJ (1984):Pre-B cell leukemia associated with chromosometranslocation1;19. Blood 63 :721-726. CarrollA, CastelberryR, CristW ( I 987a): Lackof association betweenabnormalitiesof the shortarm of chromosome 9 and either lymphomatous features of T cell phenotype in childhood acute lymphoblastic leukemia. Blood 69:735-738. CarrollAJ, RaimondiSC, Williams DL, Behm FG, BorowitzM, CastleberryRP, HarrisMB, Patterson RB,Pullen DJ,CristWM (1 987b):tdic(9;12):a nonrandomchromosomeabnormalityin childhood B- cell precursor acute lymphoblastic leukemia: a Pediatric Oncology Group Study. Blood 70:1962-1965. Carroll AJ, Crist WM, Link MP, Amylon MD, Pullen DJ, Ragab AH, BuchananGR, Wimmer RS, Vietti TJ (1990): The t( 1;14)(p34;qlI)is nonrandomand restrictedto T-cell acute lymhoblastic leukemia: a pediatriconcology group study. Blood 7 6 1220-1224. CarterTL, Watt PM, KumarR, BurtonPR, Reaman GH, SatherHN, Baker DL, Kees UR (2001): Hemizygous p16(INK4A) deletion in pediatricacute lymphoblastic leukemia predicts independent risk of relapse. Blood 97512-574. CauwelierB, DastugueN, Cools J. Poppe B, HerensC, De PA, HagemeijerA, Speleman F (2006): Molecular cytogenetic study of 126 unselected T-ALL cases reveals high incidence of TCRbeta locus rearrangementsand putative new T-cell oncogenes. Leukemia2 0 1238-1244. CauwelierB, Cave H, Gervais C, LessardM, Barin C, PerotC, van den AJ, MugneretF,ChaninC, Pages MP, GregoireMJ, JonveauxP, Lafage-PochitaloffM. Mozzicconacci MJ,TerreC, LuquetI, Cornillet-LefebvreP, Laurence B, Plessis G, Lefebvre C, Leroux D, ntoine-Poirel H, Graux C, Mauvieux L, HeimannP, ChalasC, ClappierE, VerhasseltB, Benoit Y, Moerloose BD, Poppe B, Van RN,KeersmaeckerKD, Cools J, Sigaux F, Soulier J, HagemeijerA, Paepe AD, Dastugue N, Berger R, Speleman F (2007): Clinical, cytogenetic and molecular characteristicsof 14 T-ALL patients carrying the TCRbeta-HOXA rearrangement:a study of the Groupe Francophonede CytogenetiqueHematologique. Leukemia 21 :121-128. Cave H, Such S, PreudhommeC, Poppe B, RobertA, UyttebroeckA, Malet M, BoutardP, Benoit Y, Mauvieux L, Lutz P, MechinaudF, GrardelN, MazingueF, Dupont M, MargueritteG, Pages MP, BertrandY,Plouvier E, Brunie G, BastardC, Plantaz D, Vande V, 1, HagemeijerA, Speleman F, LessardM, OttenJ, Vilmer E, DastugueN (2004): Clinical significance of HOX 11L2expression linked to t(5;14)(q35;q32), of HOXl I expression, and of SIL-TAL fusion in childhood T-cell malignancies: results of EORTC studies 5888 1 and 5895 1. Blood 103:442-450. CazzanigaG, Daniotti M, Tosi S, Giudici G, Aloisi A, Pogliani E, KearneyL, Biondi A (2001): The paired box domain gene PAX5 is fused to ETV6TELin an acute lymphoblasticleukemia case. Cancer Res 6 1 :46664670. ChapiroE,Russell L, Radford-WeissI, BastardC, LessardM, Cave H, Fert-FerrerS, BarinC, Maarek 0. Della-Valle V, Strefford JC, Berger R, HarrisonCJ, BernardOA, Nguyen-Khac F (2006): Overexpressionof CEBPAresultingfrom thetranslocationt( 14; 19)(q32;q13) of humanprecursor B acute lymphoblasticleukemia. Bfood 10:356&3563. CharrinC, ThomasX, FfrenchM,Le.QH, AndrieuxJ, Mozziconacci MJ, Lai JL, Bilhou-NaberaC, Michaux L, Bernheim A, BastardC, Mossafa H, Perot C, Maarek0, Boucheix C, LheritierV, Delannoy A, Fiere D, Dastugue N (2004): A reportfrom the LALA-94 and LALA-SA groupson hypodiploidy with 30 to 39 chromosomes and near-triploidy:2 possible expressions of a sole

REFERENCES

281

entity conferring poor prognosis in adult acute lymphoblastic leukemia (ALL). Blood 1W2444-245 1. Chen CS, Sorensen PHB, Domer PH, Reaman GH, KorsmeyerSJ, Heerema NA, Hammond GD, Kersey JH ( 1993): Molecularrearrangementson chromosome I lq23 predominatein infant acute lymphoblastic leukemia and are associated with specific biologic variables and poor outcome. Blood 81:2386-2393. ChessellsJM, SwansburyGJ,Reeves 6, Bailey CC, RichardsSM ( 1 997):Cytogeneticsandprognosis in childhood lymphoblastic leukaemia: results of MRC UKALL X. Medical Research Council WorkingParty in Childhood Leukaemia. Br J Haematol99:93-100. Chessells JM. HarrisonCJ, Watson SL, Vora AJ, RichardsSM (2002): Treatmentof infants with lymphoblastic leukaemia: results of the UK Infant Protocols 1987-1999. Br J Huematol 1 17:306-3 14. Chilcote RR, Brown E, Rowley JD (1985): Lymphoblasticleukemia with lymphomatousfeatures associated with abnormalitiesof the shortarm of chromosome 9. N. Engl J Med 3 I3:28629 1. ChimCS, Wong AS, Kwong YL (2003):Epigenetic inactivationof INK4KDKRBcell cycle pathway in acute leukemias. Ann Hematol82:738-742. CiminoG,Lo CF, Biondi A, Elia L, Lucian0A, Croce CM, MaseraG , Mandelli F, CanaaniE (1993): ALL-1 gene at chromosome L 1q23 is consistently alteredin acuteleukemiaof earlyinfancy.Blood 82:544-546. ClappierE, Cuccuini W, Cayuela JM, Vecchione D, Baruchel A, Dombret H,Sigaux F, Soulier J (2006): Cyclin D2 dysregulation by chromosomal translocations to TCR loci in T-cell acute ly mphoblastic leukemias. Leukemia2082-86. ClappierE, Cuccuini W, KalotaA, CnnquetteA, CayuelaJM, Dik WA, LangerakAW, MontpellierB, Nadel 6, Walrafen P, Delatue 0, Aurias A, Leblanc T, Dombret H, Gewirtz AM, Baruchel A, Sigaux F, Soulier J (2007): The C-MYB locus is involved in chromosomal translocation and genomic duplicationsin humanT-cell acute leukemia (T-ALL), the translocationdefining a new T-ALL subtype in very young children.Blood 1 10:1251-1 26 I . ClarkSS, McLaughlinJ, CristWM, ChamplinR, Witte ON (1988): Unique formsof the abl tyrosine kinase distinguish Ph'-positive CML from Ph'-positive ALL. Science 239:775-777. ClarkR, ByattSA, BennettCF, BramaM, MartineauM, MoormanAV, RobertsK, Secker-WalkerLM, RichardsS, Eden OB, GoldstoneAH, HarrisonCJ (2000): Monosomy 20 as a pointerto dicentric (9;20) in acute lymphoblastic leukemia. Leukemia 14:241-246. Cooley LD, ChenevertS, ShusterJJ,JohnstonDA, Mahoney DH, CarrollAJ, Devidas M, LindaSB, LauerSJ,CamittaBM (2007): Prognostic significanceof cytogenetically detectedchromosome21 anomaliesin childhood acute lymphoblasticleukemia:a PediatricOncology Groupstudy. Cancer Genet Cytogenet 175:1 17-1 24. CroceCM, Isobe M, PalumboA, Puck J, Ming J, TweardyD, EriksonJ, David M, RoveraG (1985): Gene for alpha-chain of human T-cell receptor: location of chromosome 14 region involved in T-cell neoplasms. Science 227:1044-1047. D' Achille P, SeymourJF,CampbellLJ(2006):Translocation( 14;18)(q32;q2I ) in acute lymphoblastic leukemia: a study of 12 cases and review of the literature.CancerGenet Cylogenef 171:52-56. DavidssonJ, AndersonA, PaulssonK, HeidenbladM, lsaksson M, Borg A, HeldrupJ, BehrendtzM, Panagopoulos1, Fioretos T, Johansson B (2007): Tiling resolution arraycomparativegenomic hybridization,expressionandmethylationanalysesof dup(Iq) in Burkittlymphomasandpediatric high hyperdiploidacute lymphoblasticleukemias reveal clusterednear-centromericbreakpoints and overexpressionof genes in lq22-32.3. Hum Mol Genet 16:2215-2225. De Keersmaecker K, Graux c', Odem MD, Mentens N, Somers R, Maertens J, Wlodarska I, VandenbergheP, Hagemeijer A, Marynen P, Cools J (2005a): Fusion of EMLl to ABLI in T-cell acute lymphoblastic leukemia with cryptic t(9;I4)(q34;q32).Bfood 105:48494852.

282

ACUTE LYMPHOBIASTIC LEUKEMIA

De KeersmaeckerK, MarynenP, Cools J (2005b): Geneticinsightsin the pathogenesisof T-cell acute lymphoblasticleukemia.ffaematologica90:1I 16- I 127. Diaz MO, RubinCM, HardenA, ZieminS, LarsonRA, Le BeauMM, Rowley JD ( 1990):Deletionsof interferongenes in acute lymphoblasticleukemia.N Engl J Med 322:77-82. DiccianniMB, Batova A, Yu J, Vu T, Pullen J, Amylon M, Pollock BH, Yu AL (1997): Shortened survivalafterrelapsein T-cell acutelymphoblasticleukemiapatientswith p16/p15deletions.k u k Res 21549-558. Dik WA, BrahimW.BraunC, Asnafi V, DastugueN, BernardOA, van Dongen JJ, LangemkAW, MacintyreEA, DelabesseE (2005): CALM-AFlO T-ALLexpressionprofilesarecharacterized by overexpressionof HOXA and BMIl oncogenes. Leukemia 19:1948- 1957. DomerPH, FakharzadehSS, ChenCS, JockelJ,JohansenL, SilvermanGA, KerseyJH,KorsmeyerSJ ( 1993): Acute mixed-lineageleukemiat(4;I I )(q2 I ;q23)generatesan MLL-AF4 fusion product. Proc Natl Acad Sci USA 90:7884-7888. DowningJR, Head DR, RaimondiSC, CarrollAJ, Curcio-BrintAM, HulshofMG, PullenDJ, Domer PH (1994): The der(Il)-encoded MLWAF-4fusion transcriptis consistentlydetectedin t(4;ll) (q21;q23)-containingacute lymphoblasticleukemia.Blood 83:330-335. DrexlerHG (1998): Review of alterationsof the cyclin-dependentkinaseinhibitorINK4familygenes p15, p16, p18 and p19 in human leukemia-lymphomacells. Leukemia 122345-859. Dreyling MH, Schrader K, Fonatsch C, Schlegelberger B, Haase D, Schoch C, Ludwig W, Loffler H, Buchner T, Wormann B, Hiddemann W, Bohlander SK (1998): MLL and CALM are fused to AFLO in morphologically distinct subsets of acute leukemia with translocation t( 1O;l I): both rearrangementsare associated with a poor prognosis. Blood 91 :4662-4667. DubeID, RaimondiSC, Pi D, KalousekDK (1986): A new translocation,t( 10 I4)(q24;qI I ), in T cell neoplasia. Blood 67:1 181- I 184. Eguchi-IshimaeM, Eguchi M, KempskiH, GreavesM (2008): NOTCH1 mutationcan be an early, prenatalgenetic event in T-ALL.Blood I1 1:376-378. EllisenLW, Bird J, WestDC, SorengAL, ReynoldsTC, SmithSD, SklarJ ( 199I ): TAN-1, the human homolog of the Drosophilanotch gene, is brokenby chromosomaltranslocationsin T lymphoblastic neoplasms. Cell 66:649461. EriksonJ, FingerL, SunL, ar-RushdiA, NishikuraK, MinowadaJ, FinanJ, EmanuelBS, Nowell PC, CroceCM ( 1986): Deregulationof c-myc by translocationof the alpha-locusof T-cell receptorin T-cell leukemias.Science 232:884. Fazio G , Palmi C, Rolink A, Biondi A, CazzanigaG (2008): PAXSITELacts as a transcriptional repressorcausing down-modulationof CDI9, enhances migrationto CXCL12, and confers survivaladvantagein pre-BIcells. Cancer Res. 68: 181-1 89. FernandoAA, Look AT (2003): Gene expressionprofiling in T-cell acute lymphoblasticleukemia. Semin Hematol40:274-280. FerrandoAA, Neuberg DS, StauntonJ, Loh ML, HuardC, Raimondi SC, Behm FG, Pui CH, Downing JR, Gilliland DG, Lander ES, Golub TR, Look AT (2002): Gene expression signaturesdefine novel oncogenic pathwaysin T cell acute lymphoblasticleukemia.Cancer Cell 1~75-87. FerrandoAA, HerblotS , PalomeroT, Hansen M, Hoang T, Fox EA, Look AT (2004a): Biallelic transcriptional activationof oncogenic transcriptionfactorsin T-cell acute lymphoblasticleukemia. Blood 103:1909-191 I . FerrandoAA, Neuberg DS, Dodge RK, PaiettaE, LarsonRA, WiernikPH, Rowe JM,Caligiuri MA, Bloomfield CD, Look AT (2004b): Prognostic importance of TLXl (HOXII) oncogene expression in adults with T-cell acute lymphoblastic leukaemia. Lancet 363: 535-5 36.

+

REFERENCES

283

FersterA, BertrandY, Benoit Y,Boilletot A, BeharC, MargueritteG, RobertA, MazingueF. SouilletG ( 1994): Improved survival for acute lymphoblastic leukaemia in infancy: the experience of EORTC-ChildhoodLeukaemiaCooperativeGroup.Br J Haetnntol86:284-290. First MIC Cooperative Study Group ( 1986): Morphologic, immunologic, and cytogenetic (MIC) working classification of acute lymphoblasticleukemias. Cancer Gene1 Cytogenet 23: I 89-1 97. FizzottiM, CiminoG, PisegnaS, Alimena G,QuartaroneC, Mandelli F. Pelicci PG, Lo COCO F ( 1995): Detection of homozygous deletions of the cyclin-dependentkinase 4 inhibitor (p16) gene in acute lymphoblastic leukemia and association with adverse prognostic features. Blood 85:2685-2690. Ford AM, Bennett CA, Price CM, BruinMC. van WeringER, GreavesM (1998): Fetal origins of the TEL-AMLI fusion gent:in identicaltwins with leukemia. Proc NatlAcadSci USA 95:4584-4588. FoirstierE, Schmiegelow K (2006): The incidence peaks of the childhood acute leukemias reflect specific cytogenetic aberrations.J Pediatr Hematol Oncol28:486-495. ForestierE, Gauffin F, Andersen MK, Autio K, BorgstromG, Golovleva 1, Gustafsson B. Heim S. Heinonen K, HeymanM, Hovland R, JohannssonJH, KerndrupG, Rosenquist R, SchoumansJ, Swolin B, Johansson B, Nordgren A (2008a): Clinical and cytogenetic featuresof pediatric dic (9;20)(p13.2;q 1 I .2)-positive B-cell precursoracuteIymphoblasticleukemias:a Nordicseriesof 24 cases and review of the literature.Genes Chromosomes Cancer 47: 149-158. Forestier E. Heyman M, Andersen MK, Autio K, Blennow E, BorgstromG, Golovleva 1, Heim S, Heinonen K, Hovland R, JohannssonJH, KerndrupG, Nordgren A, Rosenquist R, Swolin B, Johansson B (2008b): Outcome of ETV6/RUNXI-positive childhood acute lymphoblastic leukaemia in the NOPHO-ALL-1992protocol: Frequentlate relapses but good overall survival. Br J Hacmatol 140565472. Forestier E. Izraeli S, Beverloo B, Haas 0, Pession A, Michalova K, Stark B, Harrison CJ, Teigler-Schlegel A, Johansson B (2008~):Cytogenetic features of acute lymphoblastic and myeloid leukemias in pediatric patients with Down syndrome: an iBFM-SG study. Blood 1 I I:l575-1583. FrankelLS, Ochs J ,ShusterJJ,Dubowy R, BowmanWP, Hockenberry-EatonM, BorowitzM. Carroll AJ. SteuberCP, Pullen DJ (1997): Therapeutictrial for infant acute lymphoblasticleukemia:the PediatricOncology Groupexperience (POG 8493). J Pediatr Hematol Oncol 19:3542. GanmoreI, Bercovich D, Scott LM, Green AR, CazzanigaG, Biondi A. Basso G, CarioG, Schrappe M. Stanulla M, Strehl S, Haas OA, BinderV, BorkhardtA, TrkaJ, Bielorei B, Avigad S, StarkB, BourquinJP, Smith 0, Kempski H, lzraeli S (2007): CollaborationBetween ActivatingMutations in Jak2and Trisomy 2 I in the Acute LymphoblasticLeukemiasof Down Syndrome(DS). ASH Annual Meeting Abstracts 110, LB6. GibbonsB, MacCallumP, WattsE, RohatinerAZS, WebbD, KatzFE, Secker-WalkerLM, Temperley IJ, HarrisonCJ, Campbell RHA, Nash R, BroadbentV, Chessells JM ( 1 991): Near haploid acute lymphoblasticleukemia: seven new cases and a review of the literature.Leukemia 5:738-743. GolubTR. BarkerGF, BohlanderSK, HiebertSW, WardDC, Bray-WardP, MorganE. RaimondiSC, Rowley JD, Gilliland DG (1995): Fusion of the TELgene on 12p13 to the AML 1 gene on 21 q22 in acute lymphoblastic leukemia. Proc Natl Acad Sci USA 92:49 17-4921. GrauxC, Cools J, Melotte C, QuentmeierH. FerrandoA, Levine R, VermeeschJR, Stul M. Dutta B, Boeckx N, Bosly A, HeimannP, UyttebroeckA, MentensN, SomersR, MacLeodRA, DrexlerHG, Look AT, Gilliland DG, Michaux L, VandenbergheP, WlodarskaI, Marynen P, Hagemeijer A (2004): Fusionof NUP2 14 to ABL I on amplifiedepisomes in T-cell acute lymphoblasticleukemia. Nat Genet 36: 1084-1 089. GrauxC, Cools J, Michaux L, VandenbergheP, HagemeijerA (2006): Cytogenetics and molecular genetics of T-cell acute lymphoblastic leukemia: from thymocyte to lymphoblast. Leukemia 20:1496-1510.

284

ACUTE LYMPHOBIASTICLEUKEMIA

GreavesMF(2OOO): Moleculargenetics, naturalhistoryandthe demise of childhoodleukaemia.Eur J Cancer 35: 173-1 85. Greaves M (2005): In utero origins of childhood leukaemia. EarlyHum Dev 8 I:123-129. GreavesMF, Maia AT, Wiemels JL, Ford AM (2003): Leukemia in twins: lessons in naturalhistory. Blood 102:2321-2333. GroffenJ, HeisterkampN ( 1 987): The BClUABL hybridgene. Baillieres C h Haematoll :983-999. GroupeFrancaisde CytogenetiqueHematologique( 199 1 ): t( 10;1 1 )(p J 3- 14;q14-2I):a new recurrent translocationin T-cell acute lymphoblasticleukemias. Genes Chromosomes Cancer3:4 1 1 4 15. GroupeFrancais de Cytogenetique Hematologique ( I 993): Collaborative study of karyotypes in childhood acute lymphoblastic leukemias. Leukemia 7: 10-19. Gu Y,NakamuraT, Alder H, PrasadR, Canaani0, Cimino G, Croce CM, CanaaniE (1 992): The t (4;1 I ) chromosome translocationof human acute leukemias fuses the ALL-1 gene, related to Drosophilatrithorax,to the AF-4 gene. Cell 7 1:701-708. Hann1, VoraA, HarrisonG, HarrisonC, MartineauM, MoormanAV, Secker-WalkerLM, Eden0,Hill F, Gibson B, RichardsS (2001): Determinantsof outcome after intensifiedtherapyof childhood lymphoblastic leukaemia: results from Medical Research Council United Kingdom acute lymphoblastic leukaemia XI protocol. Br J Haematol I 1 3:103-1 14. Hansen-HaggeTE, SchaferM, Kiyoi H, Moms SW, Whitlock JA, Koch P, Bohlmann1, MahotkaC, BartramCR, Janssen J W (2002): Disruptionof the RanBP17/Hoxl1L2 region by recombination with the TCRdelta locus in acute lymphoblastic leukemias with t(5; 14)(q34;qI I). Leukemia 16:2205-2212. Harbott J, ViehmannS, BorkhardtA, Henze G, Lampert F (1997): Incidenceof TEWAMLIfusion gene analyzed consecutively in children with acute lymphoblastic leukemia in relapse. Blood 9049334937. Harewood L, Robinson H, Hams R, A1 Obaidi MJ, Jalali GR, Martineau M, Moorman AV, Sumption N, Richards S, Mitchell C, Harrison CJ (2003): Amplification of AMLl on a duplicated chromosome 21 in acute lymphoblastic leukemia: a study of 20 cases. Leukemia 17547-553. HarrisMB, ShusterJJ,CarrollA, Look AT, Borowitz MJ,CristWM, Nitschke R, PullenJ, SteuberCP, Land VJ (1992): Trisomy of leukemic cell chromosomes 4 and 10 identifies children with Bprogenitor cellacute lymphoblasticleukemiawith a very low risk of treatmentfailure:a Pediatric Oncology Group study. Blood 79:3316-3324. Harris RL, HarrisonCJ, Martineau M, Taylor KE, Moorman AV (2004): Is trisomy 5 a distinct cytogenetic subgroupin acute lymphoblasticleukemia?Cancer Genet Cytogenet 148:159-1 62. HarrisonCJ,(2007): Geneticsof T-cell Acute Lymphobla5ticLeukemia.http://online.haematologica. org/supplements/Hematology~Education~2007 .pdf. HamsonCJ,ForoniL (2002): Cytogeneticsand moleculargenetics of acute lymphoblasticleukemia. Rev Clin Exp Hematol6:91- I13. HarrisonCJ, Cuneo A, Clark R, Johansson B, Lafage-Pochitaloff M, MugneretF, Moorman AV, Secker-Walker LM ( 1998): Ten novel I I q23 chromosomal partner sites. European 1 1 q23 Workshopparticipants.Leukemia 12:811-822. Harrison CJ, Moorman AV, Broadfield ZJ, Cheung KL, Harris RL, Reza JG, Robinson HM, BarberKE, RichardsSM,Mitchell CD. Eden TO, Hann IM,Hill FG, Kinsey SE,Gibson BE, Lilleyman J, Vora A, Goldstone AH, Franklin [M.DurrantJ, Martineau M (2004): Three distinct subgroups of hypodiploidy in acute. lymphoblastic leukaemia. Br J Haematol 125:552-559. HarrisonCJ, MoormanAV, BarbexKE, BroadfieldZI,Cheung KL, HarrisRL,Jalali GR, Robinson HM, StreffordJC, StewartA, WrightS, GriffithsM, Ross FM,HarewoodL,MartineauM (2005):

REFERENCES

285

lnterphasemolecularcytogenetic screeningfor chromosomalabnormalitiesof prognostic significance in childhood acute lymphoblasticleukaemia:a UK CancerCytogeneticsGroupStudy.Br J Haematol 129:52&530. Hasle H, ClemmensenIH, Mikkelsen M (2000): Risks of leukaemiaandsolid tumoursin individuals with Down’s syndrome.k n c e t 355: 165-1 69. HatanoM, RobertsCW, Minden M, Crist WM, KorsmeyerSJ (1991): Deregulationof a homeobox gene, HOXl 1, by the t(10;14) in T cell leukemia. Science 253:79-82. Hayette S, Tigaud I. Maguer-SattaV, BartholinL, Thomas X, Chanin C, Gadoux M, Magaud JP, Rimokh R (2002): Recurrentinvolvementof the MLLgene in adultT-lineage acute lymphoblastic leukemia. Blood 99:46474649. Hebert J, Cayuela JM, Berkeley J, Sigaux F (1994): Candidate tumor-suppressorgenes MTSl (p16INK4A) and MTS2 (p151NK4B) display frequent homozygous deletions in primarycells from T- but not from B-cell lineage acute lymphoblasticleukemias. Blood 84:4038-4044. Heerema NA, Palmer CG, Weetman R, Bertolone S (1992): Cytogenetic analysis in relapsed childhood acute lymphoblasticleukemia. Leukemia 6:185-1 92. HeeremaNA, ArthurDC, SatherH, Albo V, FeusnerJ, LangeBJ, ZeltzerP, HammondD, ReamanGH (1994): Cytogenetic features of infants less than 12 months of age at diagnosis of acute lymphoblasticleukemia: impact of the tlq23 breakpointon outcome: a reportof the Childrens CancerGroup. Blood 83:2274-2284. HeeremaNA, NachmanJB, SatherHN, Sensel MG. Lee MK, HutchinsonR, Lange BJ, SteinherzPG, Bostrom B, Gaynon PS, Uckun F (1999a): Hypodiploidy with less than45 chromosomesconfers adverserisk in childhoodacutelymphoblasticleukemia:a reportfromthechildren’scancergroup. Blood 94:40364045. HeeremaNA, SatherHN, Sensel MG, Liu-MaresW, Lange BJ, BostromBC, NachmanJB, Steinhen PG, HutchinsonR, Gaynon PS, ArthurDC, Uckun FM (1999b): Association of chromosomearm 9p abnormalitieswith adverserisk in childhood acute lymphoblasticleukemia:a reportfromthe Children’sCancer Group. Blood 94: 1537-1 544. HeeremaNA, SatherHN, Sensel MG, Lee MK, HutchinsonRJ,NachmanJB, ReamanGH, LangeBJ, SteinhenPG, Bostrom BC. GaynonPS, Uckun FM (2000a): Abnormalitiesof chromosomebands 13ql2 to 13q14 in childhood acute lymphoblastic leukemia. J Clin Oncol 18:3837-3844. NachmanJB, LangeBJ, SteinherzPG, HeeremaNA, SatherHN, Sensel MG, ZhangT, HutchinsonW , Bostrom BC, Reaman GH, Gaynon PS, Uckun FM (2000b): Prognostic impact of trisomies of chromosomes 10, 17 and 5 among children with acute lymphoblastic leukemia and high hyperdiploidy (>50 chromosomes). J Clin Oncol 18:1876-1 887. HeeremaNA, SatherHN, Sensel MG, La MK, HutchinsonRJ, NachmanJB, ReamanGH, Lange BJ, SteinherzPG, Bostrom BC, GaynonPS, Uckun FM (2002): Abnormalitiesof chromosomebands 15ql3-15 in childhood acute lymphoblasticleukemia. Cancer94:1102-1110. HeercniaNA. RaimondiSC, AndersonJR, Biegel J, CamittaBM, Cooley LD, Gaynon PS, Hirsch B, Magenis RE, McGavranL, Patil S, Pettenati MJ, Pullen J, Rao K, Roulston D, Schneider NR, Shuster JJ, Sanger W, Sutcliffe MJ, van TP, Watson MS, Carroll AJ (2007): Specific extra chromosomes occur in a modal number dependent pattern in pediatric acute lymphoblastic leukemia. Genes Chromosoms Cancer463684693. HerlingM, Patel KA. Teitell MA, KonoplevaM, RavandiF, KobayashiR, JonesD (2008): HighTCLI expression and intact T-cell receptor signaling define a hyperproliferativesubset of T-cell prolymphocyticleukemia. Blood I 1 1 :328-337. Heyman M, GranderD, Brondum-Nielsen K, Liu Y, SoderhallS , EinhornS ( 1993): Deletions of the short arm of chromosome 9, including the interferon-alpha/-betagenes, in acute lymphocytic leukemia.Studies on loss of heterozygosity, parentalorigin of deleted genes and prognosis. Int J Cancer54:748-753.

286

ACUTE LYMPHOBIASTIC LEUKEMIA

Hilden JM, DinndorfPA, MeexbaumSO, SatherH, Villaluna D, HeeremaNA, McGlennenR, Smith FO, Woods WG, SalzerWL, JohnstoneHS, DreyerZ, ReamanGH (2006): Analysis of prognostic factors of acute lymphoblastic leukemia in infants: report on CCG 1953 from the Children’s Oncology Group. Blood 108:441-451. HoshinoK, Asou N, OkuboT, SuzushimaH, KiyokawaT,KawanoF, Mitsuya H (2002): The absence of the plSINK4B gene alterationsin adult patients with precursorB-cell acute lymphoblastic leukaemia is a favourableprognostic factor. Br .I Haematol I 17531-540. Hunger SP (1996): Chromosomal translocations involving the E2A gene in acute lymphoblastic leukemia: clinical featuresand molecular pathogenesis. Blood 87: 12 11- 1224. HungerSP, Galili N, CarrollAJ,CristWM. Link MP,CIearyML (1 991): The t( I; 19)(q23;p13) results in consistent fusion of E2A and PBXl coding sequences in acute lymphoblasticleukemias.Blood 77:687493. Hunger SP, Devaraj PE, Foroni L, Secker-WalkerLM, Cleary ML (1994): Two types of genomic rearrangementscreate alternative E2A-HLF fusion proteins in t( 17;l9)-ALL. Blood 83:2970-2977. HuretJL,BrizardA, SlaterR, CharrinC, BertheasMF,GuilhotF. KroesW, van Leeuwen E, SchootEV (1993): Cytogenetic heterogeneity in t( 1 I; 19) acute leukemia: clinical, hematological and cytogenetic analyses of 48 patients-updatedpublishedcases and I6 new observations.Leukemia 7:152-160. InabaT, RobertsWM, ShapiroLH,Jolly KW, RaimondiSC, Smith SD, Look AT (1992): Fusionof the leucinezippergene HLFto the E2A gene in humanacute B-lineageleukemia.Science 25753 1-534. IWCL3ThirdInternationalWorkshopon Chromosomesin Leukemia(1 980) ( 198I): Chromosomal abnormalitiesin acute lymphoblastic leukemia: structuraland numerical changes in 234 cases. Cancer Genet Cytogenez 4: 101- 1 10. IWCL3Third InternationalWorkshopon Chromosomesin Leukemia(1980) ( I 983): Chromosome abnormalities and their clinical significance in acute lymphoblastic leukemia. Cancer Res 43:868-873. JabberAl-ObaidiMS, MartineauM, BennettCF,FranklinIM,GoldstoneAH, HarewoodL, JalaliGR, PrenticeHG, RichardsSM, RobertsK, HarrisonCJ (2002): ETV6/AML1 fusion by FISHin adult acute lymphoblastic leukemia. Leukemia 16:669-674. Janssen JW, Ludwig WD, Steny W, Bartram CR (1993): SIL-TALI deletion in T-cell acute lymphoblasticleukemia. Leukemia 7:1204-1210. Johansson B, Moorman AV, Haas OA, WatmoreAE, Cheung KL, Swanton S, Secker-WalkerLM (1 998): Hematologic malignancies with t(4;I l)(q2 I ;q23)-a cytogenetic, morphologic, immunophenotypic and clinical study of I83 cases. Ltukemiu L2:779-787. KagerL, Lion T,AttarbaschiA, Koenig M, Strehl S, Haas OA, DworzakMN, SchrappeM,GadnerH, MannG (2007): Incidenceand outcomeof TCF3-PBX1-positive acute lymphoblasticleukemiain Austrian children. Haematologica 92: 1561-1564. Kaleem Z, ShusterJJ, Carroll AJ, Borowitz MJ, Pullen DJ, CamittaBM, ZutterMM, Watson MS (2000): Acute lymphoblasticleukemia with an unusualt(8; 14)(qlI.2;q32): a PediatricOncology Groupstudy. Leukemia 14:238-240. Kardon NB, Slepowitz G, Kochen JA (1982): Childhood acute lymphoblastic leukemia associated with an unusual 8; 14 translocation.Cancer Genet Cytogenet 6:339-343. Kamnan K. Andersson A. BjorgvinsdottirH, StrombeckB, Lassen C, Olofsson T, Nguyen-KhacF, BergerR, Bernard0,FioretosT,JohanssonB (2006a): Deregulationof cyclin D2 by juxtaposition with T-cell receptor alphddelta locus in t( 12; 14)(pl3;q1 I)-positive childhood T-cell acute lymphoblastic leukemia. Eur J Huematol77:27-34. KanmanK, ForestierE, Andersen MK, Autio K, BorgstromG, Heim S, Heinonen K, Hovland R, KerndrupG, JohanssonB (2006b): High incidence of the ETV6RUNXI fusion gene in paediatric

REFERENCES

287

precursorB-cell acute lymphoblasticleukaemiaswith trisomy2 1 as the sole cytogenetic change: a Nordic series of cases diagnosed 1989-2005. Br J Haematol 135:352-354. KearneyL (1999): The impact of the new FISH technologies on the cytogenetics of haematological malignancies. Br J Haematol 104:648-658. Kees UR, Heerema NA, Kumar R, Watt PM, Baker DL, La MK, Uckun FM, Sather HN (2003): Expression of HOX 11 in childhood T-lineage acute lymphoblastic leukaemia can occur in the absence of cytogenetic aberrationat 10q24 a study from the Children’sCancer Group (CCG). Leukemia 17:887-893. Kennedy MA, Gonzalez SarmientoR, Kees UR, LampertF, Dear N, Boehm T, RabbittsTH (1991): HOX 11, a homebox-containingT-cell oncogene on humanchromosome lOq24. Proc Natl Acad Sci USA 88:8900-8904. KonradM, Metzler M, Panzer S, OstreicherI, Peham M, Repp R, Haas OA, Gadner H, PanzerGrumayerER (2003): Late relapses evolve from slow-responding subclones in t( 12;21)-positive acute lymphoblastic leukemia: evidence for the persistence of a preleukemic clone. Blood 101136353640, KovacsBZ, Niggli FK, Betts DR (2004): Aberrationsinvolving 13qI2 approximately414 arefrequent secondary events in childhood acute lymphoblastic leukemia. Cancer Genet Cytogenet 151: 157- I6 I . KowalczykJP,SandbergA (1 983): A possible subgroupof ALL with 9p abnormalities.Cancer Genet Cytogenet 9:383-385. Kwong YL, Wong KF(1997): Low frequencyof TEL/AMLl in adult acute lymphoblasticleukemia. Cancer Genet Cytogenet 98: 137-138. La StarzaR, AventinA, Crescenzi B, Gorello P, Specchia G, Cuneo A, Angioni A, Bilhou-NaberaC, Boque C, Foa R, Uyttebroeck A, Talmant P, Cimino G, Martelli MF, Marynen P, Mecucci C, Hagemeijer A (2005): CIZ gene rearrangementsin acute leukemia: reportof a diagnostic FISH assay and clinical features of nine patients. Leukemia 19:16961699. LacroniqueV, Boureux A, Valle VD, Poirel H, Quang CT, MauchauffeM, BerthouC, Lessard M, BergerR, Ghysdael J, BernardOA (1997): A TEL-JAK2 fusion protein with constitutive kinase activity in human leukemia. Science 278: 1309-1 3 12. LahortigaI, De KeersmaeckerK, van VlierbergheP. GrauxC, CauwelierB, LambertF, Mentens N, Beverloo BH, PietersR, SpelemanF, OderoMD, BautersF, FroyenG, MarynenP, VandenbergheP, WlodarskaI, Meijerink JP,Cools J (2007): Duplication of the MYB oncogene in T cell acute lymphoblasticleukemia. Nat Genet in press. Lange BJ, Raimondi SC, Heerema NA, Nowell PC, Minowada J, Steinherz PE, Arenson EB, O’ConnorR, Santoli D (1992): Pediatricleukemidlymphomawith t(8;14)(q24;ql1). Leukemia 6:613-618. Lee SY. KumanoK, MasudaS, HangaishiA, TakitaJ, NakazakiK, KurokawaM, HayashiY,OgawaS, Chiba S (2005): Mutationsof the Notch1 gene in T-cell acute lymphoblasticleukemia:analysis in adults and children. Leukemia 19:1841-1843. Lemos JA, DefaveryR, Scrideli CA, Tone LG (2003): Analysis of p l 6 gene mutationsanddeletionsin childhood acute lymphoblasticleukemias. Sao Paul0 Med J 1213-62. Lillington DM, Young BD, Berger R, MartineauM, Moorman AV, Secker-WalkerLM (1998): The t( 10;1 I )(p12;q23) translocationin acuteleukaemia:a cytogeneticandclinical studyof 20 patients. Leukemia 12301-804. Liu S , Bo L. Liu X, Li C, Qin S, Wang J (2004): IGH gene involvement in two cases of acute lymphoblastic leukemia with t(14; 14)(qll;q32) identified by sequential R-banding and fluorescence in situ hybridization.Cancer Genet Cytogenet 152:141-145. LundinC, Heidenblad M, StrombeckB, Borg A, Hovland R, Heim S, Johansson B (2007): Tiling resolutionarrayCGHof dic(7;9)(pl I approximately13;p1 1 approximately13) in B-cell precursor

288

ACUTE LYMPHOBLASTIC LEUKEMIA

acute lymphoblastic leukemia reveals clustered breakpointsat 7pl I .2 approximately 12. I and 9~13.1.Cylogenet Genome Res 118:13-18. Ma SK, ChanGC,WanTS, Lam CK, Ha SY, Lau YL, Chan LC (1998): Near-haploidcommon acute lymphoblastic leukaemia of childhood with a second hyperdiploid line: a DNA ploidy and fluorescence in-situ hybridizationstudy. Br J Haemutol 103:750-755. MahmoudH, CarrollAJ, Behm F, RaimondiSC, SchusterJ, BorowitzM, LandV, PullenDJ, ViettiTJ, Crist W (1 992): The non-random dic(9;12) translocation in acute lymphoblastic leukemia is associated with B-progenitorphenotype and an excellent prognosis. Leukemia 6:703-707. Maillard I, Fang T, Pear WS (2005): Regulation of lymphoid development, differentiation,and function by the Notch pathway.Annu Rev Immunol23:945-974. Mansour MR, Linch DC,Foroni L, Goldstone AH, Gale RE (2006): High incidence of Notch-1 mutationsin adult patients with T-cell acute 1ymphoblastic leukemia. Leukemia 20:537-539. Martineau M, Clark R, Farrell DM, Hawkins JM, Moorman AV, Secker-Walker LM (1996): [sochromosomes in acute lymphoblasticleukaemia:i(21q) is a significant finding. Genes Chromosomes Cancer 17:21-30. MartineauM, Berger R, Lillington DM, MoormanAV, Secker-WalkerLM (1998): The t(6; Il)(q27; q23) translocationin acute leukemia: a laboratoryand clinical study of 30 cases. EU Concerted Action 1 lq23 Workshopparticipants.Leukemia 12:788-791. MartineauM, JalaliGR, BarberKE, BroadfieldZJ,CheungKL, LilleymanJ, MoormanAV, Richards S, RobinsonHM, Ross F, HarrisonCJ (2005): ETV6RUNXI fusion at diagnosis andrelapse:some prognostic indications. Genes ChromosomesCancer43:54-7 1. Martini A, La Starza R, Janssen H, Bilhou-NaberaC, Corveleyn A, Somers R, Aventin A, Foa R, Hagemeijer A, Mecucci C. MarynenP (2002): Recurrentrearrangementof the Ewing’s sarcoma gene, EWSRI, or its homologue, TAFI5, with the transcriptionfactor CIZ/NMP4 in acute leukemia. CancerRes 62:5408-54 12. Maseki N, HayashiY, KanekoY,SakuraiM ( 1986): Partialloss of the shortarm of chromosome9 in leukemia and lymphoma. CancerGenet Cytogenet 22:89-9 I . McGuireEA, HockettRD, Pollock KM,BartholdiMF, 0’BrienSJ, KorsmeyerSJ ( 1989):Thet( 1 1 ;14) (pl5;qI 1 ) in a T-cell acute lymphoblastic leukemia cell line activates multiple transcripts, including Ttg-I,a gene encoding a potential zinc finger protein.Mol Cell Biol9:2 124-2 132. McLean TW, Ringold S, Neuberg D, Stegmaier K, TantravahiR, Ritz J, Koeffler HP, Takeuchi S, Janssen JW, Seriu T, BartramCR, Sallan SE, Gilliland DG, Golub TR (1996): TEL/AML-I dimerizesand is associatedwith a favorableoutcome in childhood acute lymphoblasticleukemia. Blood 88:4252-4258. McPherson JD, MarraM, Hillier L, WaterstonRH, Chinwalla A, Wallis J, Sekhon M, Wylie K, Mardis ER, Wilson RK, Fulton R, Kucaba TA, Wagner-McPherson C, Barbazuk WB, Gregory SG, Humphray SJ, French L, Evans RS, Bethel G, Whittaker A: Holden JL, McCann OT, Dunham A, Soderlund C, Scott CE, Bentley DR, Schuler G, Chen HC, Jang W, GreenED, Idol JR, MaduroVV, MontgomeryKT. Lee E, Miller A, EmerlingS, Kucherlapati, Gibbs R, SchererS, Gorrell JH, SodergrenE, Clerc-BlankenburgK, TaborP, Naylor S, Garcia D, de Jong PJ, CataneseJJ, Nowak N, Osoegawa K, Qin S, Rowen L, Madan A, Dors M, Hood L, TraskB, FriedmanC, Massa H, Cheung VG, Kirsch IR, Reid T, Yonescu R. WeissenbachJ, Bruls T, Heilig R, BranscombE, Olsen A, Doggett N, Cheng JF, HawkinsT, Myers RM, Shang J, RamirezL, SchmutzJ, Velasquez 0,Dixon K, StoneNE, Cox DR, HausslerD, Kent WJ, Furey T, Rogic S, Kennedy S, Jones S, Rosenthal A, Wen G, Schilhabel M, GloecknerG, Nyakatura G, Siebert R, Schlegelberger B, KorenbergJ, Chen XN, Fujiyama A, Hattori M, Toyoda A, Yada T, Park HS, Sakaki Y, Shimizu N, Asakawa S, Kawasaki K, Sasaki T, Shintani A, Shimizu A, Shibuya K, Kudoh J, Minoshima S, Ramser J, Seranski P, Hoff C, Poustka A, Reinhardt R. Lehrach H (2001): A physical map of the human genome. Nature 4091934-94 I.

REFERENCES

289

MellentinJD, SmithSD. ClearyML ( 1989):lyl-1, a novel gene alteredby chromosomaltranslocation in T cell leukemia,codes for a proteinwith a helix-loop-helix DNA bindingmotif. Cell 58:77-83. M, Boyle JM,HarrisonCJ( 1994): Deletionof acommon MenasceLP, OrphanosV, Santibanez-Koref region on the long ann of chromosome6 in acutelymphoblasticleukaemia.Genes Chromosomes Cuncer 1026-29. Mengle-Caw L, Albertson DG, SherringtonPD, Rabbitts TH (1988): Analysis of a T-cell tumor-specificbreakpointcluster at human chromosome 14q32. Proc Natl Acad Sci USA 85:9171-9 175. Mertens F, Johansson B, Mitelman F (1994): Isochromosomesin neoplasia.Genes Chromosomes Cancer 10:221-230. Meyer C, SchneiderB, JakobS , StrehlS . AttarbaschjA, SchnittgerS, Schoch C, Jansen MW. van Dongen JJ,den Boer ML, PietersR, EnnasMG, AngelucciE, Koehl U, GreilJ, GriesingerF, Zur SU, EckertC, SzczepanskiT, Niggli FK, SchaferBW, KempskiH, BradyHJ,ZunaJ, TrkaJ, Nigro LL, Biondi A. Delabesse E, MaclntyreE, StanullaM, SchrappeM, Haas OA, BurmeisterT, DingermannT, KlingebielT, MarschalekR (2006): The MLL recombinomeof acuteleukemias. Leukemia 20711-784. Michael P M , Levin MD, CarsonOM (1984): Translocation1; 19-a new cytogeneticabnormalityin acute lymphocyticleukemia. Cancer Genet Cytogenei 12333-341. MirebeauD. AcquavivaC, SuciuS, BertinR, RobertA, BoutardP, MechinaudF. PlouvierE, OttenJ, Vilmer E, Cave H (2006): The prognostic significance of CDKN2A, CDKN2B and MTAP inactivation in B-lineage acute lymphoblasticleukemia of childhood. Results of the EORTC studies 58881 and 58951. Haematologica 91:881-885. Mitelman F, JohanssonB, MertensF, editors(2008): MitelmanDatabaseof ChromosomeAberrations in Cancer.http://cgap.nci.nih.gov/ChromosomeslMitelman. MoormanAV, HagemeijerA, CharrinC, RiederH, Secker-WalkerLM ( 1998): The translocations, t( 11;19)(q23;p13.1)and t( 11;19)(q23;~13.3):a cytogenetic and clinical profile of 53 patients. European 1 lq23 workshopparticipants.Leukemia 12:805-810. MoormanAV, RichardsSM, MartineauM, CheungKL, RobinsonHM,Jalali CR, BroadfieldZJ, HarrisRL, TaylorKE, Gibson BE, HannIM, Hill FG, Kinsey SE, EdenTO, MitchellCD, Harrison CJ (2003):Outcomeheterogeneityin childhoodhigh-hyperdiploidacuteIymphoblasticleukemia. Blood 102:2756-2762. MoormanAV, RaimondiSC, Pui CH, Baruchel A, Biondi A, CarrollAJ, ForestierE, Gaynon PS, HarbottJ, HarmsDO, HeeremaN, PietersR, SchrappeM, SilvermanLB, VilmerE, HarrisonCJ (2005): No prognosticeffect of additionalchromosomalabnormalitiesin children with acute lymphoblasticleukemiaand I lq23 abnormalities.Leukemia 19557-563. MoormanAV, HarrisonCJ. Buck GA, RichardsSM, Secker-WalkerLM, MartineauM, Vance GH. CherryAM, HigginsRR, FieldingAK, ForoniL, PaiettaE,TallmanMS, Litzow MR, WiernikPH, Rowe JM, GoldstoneAH, Dewald GW (2007a): Karyotypeis an independentprognosticfactorin adult acute lymphoblasticleukemia (ALL):analysisof cytogeneticdatafrom patientstreatedon the MedicalResearchCouncil(MRC)UKALLXIEastemCooperativeOncology Group(ECOC) 2993 trial.Blood 109:3189-3 197. MoormanAV, RichardsSM, Robinson HM, StreffordJC, Gibson BE, Kinsey SE, Eden TO. Vora AJ, Mitchell CD, HarrisonCJ (2007b): Prognosisof childrenwith acute lymphoblastic leukemia (ALL) and intrachromosomalamplificationof chromosome21 (iAMP21). Blood 109:2327-2330. MuftiGJ,HamblinTJ,OscierDG, JohnsonS ( I 983): CommonALL withpre-B-cell featuresshowing (8;14) and (14;18) chromosometranslocations.Blood 62:1142-1146. MullighanCG,GoorhaS, RadtkeI, MillerCB,Coustan-SmithE. DaltonJD,CirtmanK. MathewS , Ma J , Pounds SB, Su X, Pui CH. Relling MV, Evans WE, ShurtleffSA. Downing JR (2007):

290

ACUTE LYMPHOBLASTIC LEUKEMIA

Genome-wide analysis of genetic alterations in acute lymphoblastic leukaemia. Nature 446:758-764. NachmanJB, HeeremaNA, SatherH, CamittaB, ForestierE. HarrisonCJ, Dastugue N, SchrappeM, Pui CH, Basso G, SilvermanLB, Janka-SchaubGE(2007): Outcomeof treatmentin childrenwith hypodiploid acute lymphoblasticleukemia. Blood I 1 0 1 I 12-1 115. Nagel S, KaufmannM, Drexler HG, MacLeod RA (2003): The cardiachomeobox gene N M 2 - 5 is deregulatedby juxtapositionwith BCLI1B in pediatricT-ALLcell lines via a novel t(5; 14)(q35.I; q32.2). CancerRes 6353294334. Ohnishi H, KawamuraM, Ida K, Sheng XM, HanadaR, Nobori T, YamamoriS. HayashiY (1995): Homozygousdeletions of p l 6 M T S1 gene are frequentbut mutationsareinfrequentin childhood T-cell acute lymphoblastic leukemia. Blood 86: 1269- 1275. OnoderaN, McCabeNR, RubinCM ( 1992):Formationof a hyperdiploidkaryotypein childhoodacute lymphoblastic leukemia. Blood 80203-208. OshimuraM, FreemanAI, SandbergAA (1977): Chromosomesand causationof humancancer and leukemia.XXVI.Bandingstudies in acutelymphoblasticleukemia(ALL).Cancer40:116 1-1 172. PallisgaardN. HoklandP, RiishojDC.Pederson6,JorgensenP ( 1998):Multiplexreversetranscriptionpolymerase chain reaction for simultaneous screening of 29 translocations and chromosomal aberrationsin acute leukemia. Blood 92574-588. PaulssonK, HorvatA, FioretosT, MitelmanF. JohanssonB (2005a): Formationof der(19)t(1 :19)(q23; pl3) in acute lymphoblasticleukemia. Genes ChromosomesCancer42: 144-148. Paulsson K. Morse H, FioretosT,BehrendtzM, StrombeckB, JohanssonB (2005b): Evidence for a single-step mechanism in the origin of hyperdipbidchildhood acute lymphoblastic leukemia. Genes ChromosomesCnncer 44: 1 13- 122. Paulsson K,Jonson T, Ora I, Olofswn T, Panagopoulos I, JohanssonB (2007): Characterisationof genomic translocationbreakpointsand identificationof an alternativeTCF3/PBXl fusion transcriptin t( 1 ;I9)(q23;p13)-positiveacute lymphoblasticleukaemias. Br J Haemalol 138:196-201. Paulsson K, HorvatA, StrombeckB, Nilsson F, HeldrupJ, BehrendtzM, ForestierE, Anderson A, FioretosT, JohanssonB (2008):Mutationsof FLT3, NRAS, KRAS, andPTPNI 1 are frequentand possibly mutuallyexclusive in high hyperdiploidchildhoodacute Iymphoblasticleukemia.Genes ChromosomesCancer 47:26-33. Pellet P, Hillion J, CarrollAJ, CristWM,BrouetJC, Tsapis A (1991): Heterogeneityof the breakpoint localization in malignant cells with a 9p I 1 chromosomalabnormality.Leukemia 5:468-472. PietersR, SchrappeM, De LP, Hann1, De RG, Felice M, Hovi L, LeblancT, SzczepanskiT, FersterA, JankaG,RubnitzJ, SilvermanL, StaryJ, CampbellM, Li CK, MannG, SuppiahR, Biondi A, Vora A, Valsecchi MG (2007): A treatment protocol for infants younger than 1 year with acute lymphoblastic leukaemia (Interfant-99):an observational study and a multicentre randomised trial. Lancet 370:240-250. PriviteraE, KampsMP, HayashiY,lnabaT, ShapiroLH, RaimondiSC, Behm F,HendershotL, Carroll AJ, BaltimoreD ( 1992):Differentmolecularconsequencesof the I ;19 chromosomaltranslocation in childhood B-cell precursoracute lymphoblasticleukemia. Blood 79:1781- 1788. PrzybylskiGK, Dik WA, WanzeckJ, GrabarczykP, MajunkeS, Martin-SuberoJI, SiebertR, Dolken G,Ludwig WD, VerhaafB, van Dongen JJ, Schmidt CA, LangerakAW (2005): Disruptionof the BCLl LB gene throughinv(l4)(q I I .2q32.3 I ) results in the expressionof BCLl1B-TRDC fusion transcriptsand is associated with the absence of wild-type BCLl 1B transcripts in T-ALL. Leukemia 19:201-208. Pui C-H (1992): Acute leukemias with the t(4;l l)(q21;q23). LRuk Lymphoma7:173-179. Pui CH, Raimondi SC, Dodge RK, RiveraGK, Fuchs LA, AbromowitchM, Look AT, FurmanWL, Crist WM, Williams DL ( 1989): Prognosticimportanceof structuralchromosomalabnormalities

REFERENCES

291

in childrenwith hyperdiploid(greaterthan50 chromosomes)acute1ymphoblasticleukemia.Blood 73: 1963-1967. Pui C-H, CarrollAJ, RaimondiSC, LandVJ, CristWM,ShusterJJ,WilliamsDL, Pullen J, Borowitz MJ, Behm FG, Look AT (1990): Clinicalpresentation,karyotypiccharacterization, and treatment outcomeof childhoodacutelymphoblasticleukemiawith a near-haploidorhypodiploid<45 line. Blood 75:1170-1177. Pui C-H. CarrollAJ, RaimondiSC, Schell MJ,HeadDR, ShusterJJ,CristWM,BorowitzMJ, Link MP, Behm FG, SteuberCP,Land VJ (1992): Isochromosomesin childhoodacute lymphoblastic leukemia:a collaborativestudy of 83 cases. Blood 792384-239 1. Pui CH, RibeiroRC, CampanaD, RaimondiSC, HancockML, Behm FG. SandlundJT,RiveraGK, EvansWE, CristWM,KranceR (19%): Prognosticfactorsin the acute lymphoidand myeloid leukemiasof infants.Leukemia 10952-956. h i CH, Relling MV, Downing JR (2004): Acute lymphoblastic leukemia. N Engl J Med 350: 1535-1548. Quelle DE, Zindy F, AshmunRA, SherrCJ (1995): Alternativereadingframesof the INK4a tumor suppressorgene encode two unrelated proteins capable of inducing cell cycle arrest. Cell 83:993-1000. RabbittsTH ( I 994): Chromosomaltranslocationsin humancancer.Nature 372:143-149. RabbittsTH ( 1998): LMO T-cell translocationoncogenes typify genes activatedby chromosomal translocationsthat alter transcriptionand developmentalprocesses. Genes Dev 12: 265 1-2657. RadichJP,KopeckyKJ, BoldtDH, HeadD, Slovak ML, BabuR, KirkJ, Lee A, KesslerP,Appelbaum F, Gehly G ( 1994):Detectionof BCR-ABL fusiongenes in adultacutelymphoblasticleukemiaby the polymerasechain reaction.kukemiu 8:1688-1695. RaimondiSC, h i CH, Head DR, Rivera G, Behm FG (1993): Cytogeneticallydifferentleukemic clones at relapseof childhoodacute lymphoblasticleukaemia.Blood 82576-580. RaimondiSC, Pui C-H, HancockML, Behm FG, Filatov L, Rivera GK (1996): Heterogeneityof hyperdiploid(5 1-67) childhoodacute lymphoblasticleukemia.Leukemia 10:213-224. RaimondiSC, Zhou Y,MathewS, ShurtleffSA, SandlundJT, RiveraGK, Behm FG, h i CH (2003): Reassessmentof the prognostic significance of hypodiploidyin pediatric patients with acute lymphoblasticleukemia. Cancer 98:27 15-2722. RaimondiSC, Zhou Y,ShurtleffSA, RubnitzJE,Pui CH, Behm FG (2006): Near-triploidyand neartetraploidyin childhood acute lymphoblasticleukemia:association with B-lineage blast cells carryingthe ETVGRUNXI fusion,T-lineageimmunophenotype,andfavorableoutcome.Cancer Genet Cytogenet 169:50-57. RaynaudS, Cave H, BaensM, BastardC, CacheuxV, GrosgeorgeJ, Guidal-GirouxC, GuoC, Vilmer E. MarynenP, GrandchampB (1996a): The 1221 translocationinvolvingTEL anddeletionof the otherTEL allele: two frequentlyassociatedalterationsfound in childhoodacute lymphoblastic leukemia.Blood 87:2891-2899. RaynaudSD, MauvieuxL, CayuelaJM,BastardC, Bilhou-NaberaC, DebuireB, Bones D, Boucheix C, CharrinC, Fiere D, GabertJ (1996b): TEUAMLI fusion gene is a rareevent in adultacute lymphoblasticleukemia.Leukemia 1 0 1529-1530. RaynaudSD, DastugueN, Zoccola D, ShurtleffSA, Mathew S, RaimondiSC ( 1999): Cytogenetic abnormalitiesassociatedwith the t( 12;21):a collaborativestudy of 169 childrenwith t( 12;21)positive acute lymphoblasticleukemia.Leukemia 13:1325-1 330. ReamanGH, SpostoR, Sense1MG,LangeBJ,FeusnerJH,HeeremaNA,LeonardM, HolmesEJ,Sather HN,PendergrassTW,JohnstoneHS, O’BrienRT, SteinherzPG,Zeltzer PM,GaynonPS, TriggME, Uckun FM (1999): Treatmentoutcomeandprognosticfactorsfor infantswith acutelymphoblastic leukemiatreatedon two consecutivetrialsof thechildren’sCancerGroup.J Clin Oncol17:445-455.

292

ACUTE LYMPHOBIASTIC LEUKEMIA

RiederH, SchnittgerS, Bodenstein H, Schwonzen M. WormannB, Ludwig WD, Hoelzer D, Fonatsch C (1995): dic(9;20): a new recurrentchromosome abnormality in adult acute lymphoblastic leukemia. Genes Chromosomes Cancer 1354-6 I . RobinsonHM, BroadfieldZJ,CheungKL, HarewoodL, HamsRL, JalaliGR, MartineauM,Moorman AV, Taylor KE, Richards S. Mitchell C, HarrisonCJ (2003): Amplification of A M L l in acute lymphoblastic leukemia is associated with a poor outcome. Leukemia I7:2249-2250. Robinson HM, Taylor KE, Jalali GR, Cheung KL, Hamson CJ, MoormanAV (2004): t(14;19)(q32; ql3): a recurrenttranslocationin B-cell precursoracute lymphoblasticleukemia. Genes Chromosomes Cancer 39:88-92. RobinsonHM, MartineauM, HarrisRL, BarberKE, JalaliGR, Moorman AV, StreffordJC, Broadfield ZJ,Cheung KL, HarrisonCJ (2005): Derivative chromosome 9 deletions are a significant feature of childhood Philadelphiachromosomepositive acute lymphoblastic leukaemia.Leukemia 19564-57 I . Robinson HM, Harrison CJ, Moorman AV, Chudoba I, Strefford JC (2007): Intrachromosomal amplification of chromosome 2 1 (iAMP21) may arise from a breakage-fusion-bridge cycle. Genes Chromosomes Cancer 46:3 18-326. Romana SP. Le Coniat M, Berger R (1994): t(12;21): a new recurrent translocation in acute lymphoblasticleukemia. Genes Chromosomes Cancer 9: 186-191. Romana SP, Mauchauffe M, Le Coniat M, Chumakov I, Le Paslier D, Berger R, Bernard OA ( 199Sa):The t( 12;2I ) of acute lymphoblasticleukemia results in a tel-AMLI gene fusion. Blood 85:3662-3670. Romana SP, Poirel H, Leemiat M, Flexor MA. Mauchauffe M,Jonveaux P, Berger R, BernardOA ( 1995b): High frequencyoft( 12;2I ) in childhood B-lineage acute lymphoblasticleukemia.Blood 86:4263-4269. Ross ME, ZhouX, Song G, ShurtleffSA, GirtmanK, Williams WK, Liu HC, Mahfouz R, Raimondi SC, Lenny N, Patel A, Downing JR (2003): Classification of pediatric acute lymphoblastic leukemia by gene expression profiling.Blood I02:2951-2959. Rowley JD. Diaz MO, Espinosa R HI, Patel Y,Van Melle E, Ziemin S, Taillon-Miller P, Lichter P, EvansGA. KerseyJH. WardDC, DommerPH. Le Beau MM (1990): Mappingchromosomeband 1 lq23 in human acute leukemia with biotinlated probes: identification of 1 lq23 translocation breakpointswith a yeast artificialchromosome. Proc Natl Acud Sci USA 87:9358-9362. Royer-PokoraB, Loos U, Ludwig WD (199 I): “3-2, a new gene encoding a cysteine-richprotein with the LIM motif, is overexpressed in acute T-cell leukaemia with the t(l1;14)(p13;ql I ) . Oncogene 6: 1887-1 893. Russell W,AkasakaT, Majid A, Sugimoto KJ, LoraineKE, Nagel I, HarderL, Claviez A, Gesk S, MoormanAV, Ross F, Mazzullo H, StreffordJC, SiebertR, Dyer MJ, HarrisonCJ (2008): t(614) (p22;q32): a new recurrent1GH translocationinvolving ID4 in B-cell precursoracute lymphoblastic leukemia (HCP-ALL).Blood 1 I 1:387-391. Schaad K, StrombeckR, MandahlN, AndersenMK, Heim S, MertensF, JohanssonB (2006): FISH mapping of i(7qj in acute leukemias and myxoid liposarcoma reveals clustered breakpointsin 7pl I .2: implications for formationand pathogenetic outcome of the idic(7)(pll.2). Cytogenet Genome Res 1 14: i 26- 130. SchoumansJ, JohanssonB, CorcoranM. KuchinskayaE, Golovleva 1, GranderD, ForestierE, StaafJ, Borg A, GustafssonB, Blennow E, NordgrenA (2006): Characterisationof dic(9;20)(p I 1 -13;qll) in childhood B-cell precursor acute lymphoblastic leukaemia by tiling resolution array-based comparativegenomic hybridisationreveals clustered breakpointsat 9p 13.2 and 20q 1 I .2. Br J Haematol 135:492-499. Schultz KR, Bowman WP, Slayton W, Aledo A. Devidas M, SatherH, Borowitz MJ, Davies SM, Trigg M, Pasut B, JorstadD, Eslinger T, Burden LE, Wang C, RutledgeR, Gaynon PS, Carroll

REFERENCES

293

AJ, Heerema NA, Winick N, Hunger S, Carroll WL, Camitta B (2007a): Improved early event free survival (EFS) in children with Philadelphiachromosome-positive(Ph + ) acute lymphoblastic leukemia (ALL) with intensive imatinib in combination with high dose chemotherapy:Children’sOncology Group(COG) Study AALL003I . ASH Annual Meeting Abstracts 1 10:4. SchultzKR, Pullen DJ, SatherHN, ShusterJJ,Devidas M, BorowitzMJ, CarrollAJ, HeeremaNA, RubnitzJE, Lob ML, Raetz EA, Winick NJ, HungerSP. CarrollWL. Gaynon PS, CamittaBM (2007b): Risk- and response-basedclassificationof childhoodB-precursoracute lymphoblastic leukemia:a combinedanalysisof prognosticmarkersfrom the PediatricOncology Group(POG) and Children’sCancerGroup(CCG). Blood 109:926-935. Secker-WalkerLM,(1 997): Chromosomes andCenes in Acute Lymphoblastic Leukaemia. New York: Chapmanand Hall. Sccker-WalkerLM, Lawler SD, Hardisty RM (1 978): Prognostic implicationsof chromosomal findings in acute lymphoblasticleukaemiaat diagnosis.Br Med J 2:1529-1530. Secker-WalkerLM, Chessells JM, Stewart EL, SwansburyGJ, RichardsS, Lawler SD (1989): Chromosomesandotherprognosticfactorsin acutelymphoblasticleukaemia:a long-termfollowup. Br J Haematol72:336-342. Secker-WalkerLM, BergerR, FenauxP, Lai JL, Nelken B,CarsonM, MichaelPM, HagemeijerA, Harrison CJ, Kaneko Y, Rubin CM (1992): Prognostic significance of the balanced t(l;19) and unbalanced der(19)t(l;19) translocationsin acute lymphoblastic leukemia. Leukemia 6~363-369. ShearerBM, Flynn HC, KnudsonRA, KetterlingRP (2005): InterphaseFISH to detect PBXlE2A fusion resultingfrom the der(19)t(1; 19)(q23;pl3.3)or t( I ; 19)(q23;p13.3) in paediatricpatients with acute lymphoblasticleukaemia.Br J Huematol 129:45-52. ShurtleffSA, Buijs A, Behm FG,RubnitzJE, RaimondiSC, HancockML, ChanGC-H, Pui C-H, GrosveldG.DowningJR (1995): TEUAML1fusion resultingfrom a cryptict(12;21) is the most common genetic lesion in pediatricALL and defines a subgroupof patientswith an excellent prognosis.Leukemia 9: 1985-1989. Sinclair PB, SorourA, MartineauM,HarrisonCJ, Mitchell WA, O’Neill E, ForoniL (2004): A fluorescencein situ hybridizationmap of 6q deletions in acute lymphocyticleukemia:identification and analysis of a candidatetumorsuppressorgene. Cancer Res 64:4089-4098. Slater R, Smit E. Kroes W, JotterandBellomo M, MuhlematterD, HarbottJ, Behrendt H, Hahlen K, Veerman AJP, Hagemeijer A (1995): A non-randomchromosome abnormality found in precusor-Blineage acute lymphoblasticleukaemia:dic(9;2O)(pl?3;q1 1). Leukemia 9:1613-1619. SlaterRM, von DrunenE, KroesWG, WeghuisDO, van den BE, Smit EM, Does-vanden Berg A, van WeringE, HahlenK, CarrollAJ,RaimondiSC, BeverlooHB (2001): t(7;12)(q36;p13)andt(7;12) (q32;p13)-translocations involving ETV6 in children18 monthsof age or youngerwith myeloid disorders.Leukemia 15915-920. Soenen V, Lepelley P, Cyan E, PreudhommeC, Lai JL, BautersF, Fenaux P, Quesnel B (2001): Prognosticsignificance of p16INK4a immunocytochemistryin adult ALL with standardrisk karyotype.Leukemia 15:1054-1059. Soler G,Radford-Weiss1, Ben-AbdelaliR, MahlaouiN, PonceauJF. MacintyreEA, VekemansM, BernardOA. RomanaSP (2008) Fusion of ZMIZl to ABLl in a B-cell acute lymphoblastic leukaemiawith a t(9;1O)(qW,q22.3) translocation.Leukemia 2 2 1278-1280. SoulierJ, Trakhtenbrot L, NajfeldV, LiptonJM,MathewS, Avet-LoiseauH, De BraekeleerM, Salem S, BaruchelA, RaimondiSC, RaynaudSD (2003): Amplificationof bandq22 of chromosome21, includingAMLI, in older childrenwith acute lymphoblasticleukemia:an emergingmolecular cytogenetic subgroup.Leukemia 17:1679-1 682.

294

ACUTE LYMPHOBIASTIC LEUKEMIA

Soulier J, ClappierE, Cayuela JM, Regnault A. Garcia-PeydroM, DombretH, BaruchelA, Toribio ML, Sigaux F (2005): HOXAgenes are included in genetic andbiologic networksdefininghuman acute T-cell leukemia (T-ALL). Blood 106:274-286. SpelemanF, CauwelierB, DastugueN, Cools J, Verhasselt B, Poppe B, Van Roy N, Vandesompele J, Graux C, Uyttebroeck A, Boogaerts M, De Moerloose B, Benoit Y,Selleslag D, Billiet J, Robert A, Huguet F, VandenbergheP, De Paepe A, Marynen P. Hagemeijer A (2005): A new recurrent inversion, inv(7)(p15q34), leads to transcriptional activation of HOXAlO and HOXAl I in a subset of T-cell acute lymphoblasticleukemias. Leukemia 19:358-366. StarkB, Jeison M, GobuzovR, Krug H, Glaser-GabayL, LuriaD, El HasidR, HarushMB, Avrahami G, Fisher S, Stein J, Zaizov R, Yaniv I (2001): Near haploid childhood acute lymphoblastic leukemia masked by hyperdiploidline: detection by fluorescence in situ hybridization.Cancer Genet Cyfogener l28:108-113. Stergianou K, Fox C, Russell NH (2005): Fusion of NUP214 to ABLl on amplified episomes in T-ALL-implications for treatment.Leukemia 19:1680-1 68 I . StreffordJC. Van Delft W Robinson . HM, WorleyH, Yiannikouris0,Selzer R, RichmondT, HannI, Bellotti T, RaghavanM, Young BD, SahaV, HarrisonCJ(2006): Complex genomic alterationsand gene expression in acute lymphoblastic leukemia with intrachromosomalamplificationof chromosome 2 I , Proc Natl Acad Sci USA I03:8 167-8 172. StreffordJC, Worley H, BarberK, WrightS , Stewan AR, Robinson HM, Bettney G , Van Delft FW, AthertonMG, Davies T, GriffithsM, Hing S, Ross FM,Talley P, SahaV, MoormanAV, HarrisonCJ (2007): Genome complexity in acute lyniphoblasticleukemiais revealedby array-basedcomparative genomic hybridization.Oncogene 26:4306-43 1 8. StrehlS , KonigM, DworzakMN, KalwakK, Haas OA (2003):PAX5ETV6fusiondefinescytogenetic entity dic(9;12)(p13;p13). Leukemia 17:1121-1123. Su XY, Busson M,V, Della V, Ballerini P, Dastugue N, TalmantP, FerrandoAA, Baudry-BluteauD, RomanaS , BergerR,BernardOA (2004): Varioustypes of rearrangementstargetTLX3 locus in T-cell acute 1ymphoblasticleukemia. Genes Chromosomes Cancer 4 I :243-249. Su X, DrabkinH, ClappierE, MorgadoE, Busson M, RomanaS, Soulier J, Berger R, BernardOA, Lavau C (2006a): Transformingpotential of the T-cell acute lymphoblastic leukemia-associated homeobox genes HOXA13, TLXI, and TLX3. Genes ChromosomesCancer 45:84&855. Su XU, la-Valle V, ndre-SchmutzI, LemercierC, Radford-WeissI, Ballerini P, LessardM, LafagePochitaloff M, MugneretF, Berger R, Romana SP, BernardOA, Penard-LacroniqueV (2006b): HOXI 1L2mLX3 is transcriptionallyactivatedthroughT-cell regulatoryelementsdownstreamof BCLl 1B as a result of the t(5;14)(q35;q32). Bfood 108:4198-4201. TanabeS, BohlanderSK, Vignon CV, EspinosaR 111, ZhaoN, Strissel PL,Zeleznik-LeNJ, Rowley JD ( 19%):AFlO is split by MLL andHEAB, a humanhomolog to a putativeCaenorhabditiselegans ATP/GTP-bindingprotein in an invins(1 0 1l)(p12:q23q 12). Blood 88:3535-3545. Testoni N, ZaccariaA, MartinelliG, Pelliconi S, Buzzi M. FarabegoliP, PanzicaG, TuraS (1993): t (8;14)(ql1;q32) in acute lymphoid leukemia: descriptionof two cases. Cancer Genet Cyfogenel 67:55-58. ThirmanMJ, LevitanDA, KobayashiH, Simon MC, Rowley JD (1 994): Cloning of ELL,a gene that fuses to MLL in a t(l1;19)(q23;p13.1) in acute myeloid leukemia. Proc Natl Acad Sci USA 91:12110-12114. Tosi S , Harbott J, Teigler-Schlegel A, Haas OA, Pirc-DanoewinataH, HarrisonCJ, Biondi A, Cazzaniga G, Kempski H, Scherer SW, Kearney L (2000): t(7;12)(q36;p13). a new recurrent translocationinvolving ETV6 in infant leukemia. Genes Chromosomes Cancer 29:325-332. UKCCGUnited KingdomCancerCytogeneticsGroup( I 992): Translocationsinvolving 12p in acute myeloid leukemia:associationwith priormyelodysplasiaandexposureto mutagenicagents.Genes ChromosomesCancer 5252-254.

REFERENCES

295

Van den Berghe H, David G, Broeckaert-VanOA, Louwagie A, Verwilghen R,Casteels-Van DM, EggermontE. Eeckels R ( 1979): A new chromosomeanomaly in acute lymphoblastic leukemia (ALL). Hum Genet 46: 173- 180. van der BurgM, Poulsen TS, HungerSP, Beverloo HB, Smit EM, Vang-Nielsen K, LangerakAW, van Dongen JJ (2004): Split-signal FISH for detection of chromosomeaberrationsin acute lymphoblastic leukemia.Leukemia 18:895-908. van Oostveen J, Bijl J, RaaphorstF, WalboomersJ, MeijerC (1999): The role of homeobox genes in normal hematopoiesis and hematological malignancies. Leukemia 13:1675-1 690. Van Rhee F, KasprzykA, JarnilA, Dickinson H, Lin F, Cross NCP, Galvin MC, GoldmanJM, SeckerWalkerLM ( 1995): Detection of the BCR-ABL gene by reverse transcriptiodpolymerasechain reactionand fluorescencein situ hybridizationin a patientwith Philadelphiachromosomenegative acute lymphoblasticleukaemia. Br J Haematol90:225-228. van Vlierberghe P,van GM, Beverloo HB, Lee C, Helgason T, Buijs-GladdinesJ, Passier M, van WeringER, VeermanAJ, Kamps WA. MeijerinkJP,Pieters R (2006):The crypticchromosomal deletion del(ll)(p12p13) as a new activation mechanism of LM02 in pediatric T-cell acute lymphoblastic leukemia. Blood I08:3520-3529. VilimasT, MascarenhasJ, PalomeroT, MandalM, Buonamici S, Meng F, Thompson B, SpauldingC, MacarounS, Alegre ML, Kee BL, FerrandoA, Miele L, Aifantis I (2007): Targeting the NFkappaB signaling pathway in Notch I -induced T-cell leukemia. Nut Med 13:70-77. von Bergh AR, van DE, van Wering ER, van Zutven LJ, HainmannI, LonnerholmG, MeijerinkJP, PietersR, Beverloo HB (2006):High incidenceof t(7;12)(q36;p13) in infantAML but not in infant ALL, with a dismal outcome and ectopic expression of HLXB9. Genes ChromosomesCancer 45:731-739. Wada M, BartramCR, NakamuraH, Hachiya M, Chen DL, Borenstein J, Miller CW, Ludwig L, Hansen-HaggeTE, Ludwig WD (1993):Analysis of p53 mutationsin a large series of lymphoid hematologic malignanciesof childhood. Blood 82:3163-3 169. WakabayashiY, WatanabeH. lnoue J, Takeda N, Sakata J, Mishima Y, Hitomi J, Yamamoto T, UtsuyamaM, Niwa 0, Aizawa S, KominamiR (2003): Bcll1b is requiredfor differentiationand survival of alphabetaT lymphocytes. Nut lmmunol4533-539. WangJ, Jani-SaitSN, Escalon EA, CarrollAJ, de Jong PJ, Kirsch IR, Aplan PD (2000): The t( 14;21) (q 1 1.2;q22)chromosomal translocation associated with T-cell acute 1ymphoblastic leukemia activates the BHLHB1 gene. Proc Natl Acad Sci USA 97:3497-3502. Weng AP, FerrandoAA, Lee W,Moms JP,SilvermanLB, Sanchez-lrizanyC, Blacklow SC, Look AT, AsterJC(2004):Activatingmutationsof NOTCHI in humanT cell acute lymphoblasticleukemia. Science 306:269-27 1 , Weng AP, Millholland JM, Yashiro-OhtaniY, Arcangeli ML, Lau A. Wai C, Del BC, RodriguezCG, Sai H, TobiasJ, Li Y,Wolfe MS, ShachafC, FelsherD, Blacklow SC. PearWS, AsterJC(2006): cMyc is an importantdirect targetof Notch1 in T-cell acute lymphoblastic leukemizdymphoma. Genes Dev 20:2096-2 109. Williams DL, Look AT, Melvin SL,RobersonPK, Dahl G, HakeT, StassS (1984): New chromosomal translocations correlate with specific immunophenotypesof childhood acute lyrnphoblastic leukemia. Cell 36: I01- 109. Xia Y, Brown L, YangCY, Tsan JT,Siciliano MJ,EspinosaR 111, LeBeau MM, Baer RJ (1991):TAL2, a helix-loophelix gene activatedby the (7;9)(q34;q32)translocationin humanT-cell leukemia. ProcNatl AcadSci USA 88:1141&11420. Yamada Y, Hatta Y, MurataK, SugawaraK, Ikeda S, Mine M, Maeda T, HirakataY, KamihiraS, Tsukasaki K, Ogawa S, Hirai H, KoefflerHP,Tomonaga M (1997): Deletions of p I5 and/orp I6 genes as a poor-prognosisfactor in adult T-cell leukemia. J Clin Oncol 15: 1778-1785.

296

ACUTE LYMPHOBIASTICLEUKEMIA

Yamamoto K, Seto M, Komatsu H, Iida S, Aka0 Y, Kojima S, KoderaY, NakazawaS, Ariyoshi Y, TakahashiT (1993): Two distinct portions of LTGl9ENL at 1 9 ~ 1 3are involved in t(l1;19) leukemia. Oncogene 8:2617-2625. Yeoh EJ, Ross ME, Shurtleff SA, Williams WK. Patel D, Mahfouz R, Behm FG, Raimondi SC, Relling MV, Patel A, Cheng C, CampanaD, Wilkins D, Zhou X, Li J, Liu H, Pui CH, EvansWE, Naeve C, Wong L, Downing JR (2002): Classification, subtype discovery, and prediction of outcome in pediatric acute lymphoblastic leukemia by gene expression profiling. Cancer CeN 1 :133-143. ZhongCH, PrimaV, Liang X, Frye C, McGavranL, Meltesen L, Wei Q, BoomerT, Varella-GarciaM, GumpJ, Hunger SP (2008): E2A-ZNF384 and NOLl-E2A fusion created by a cryptic t( 12;19) (p13.3; p13. 3) in acute leukemia. Leukemia 22:723-729. Zhou M, Gu L, Yeager AM, Findley HW ( I 997): Incidence and clinical significance of CDKNY MTSIP16ink4A andMTS2PI5ink4Bgene deletionsin childhood acute lymphoblasticleukemia. Pediatr Hematol Oncol 14:141-150. Zhu YM, Zhao WL, Fu J E Shi JY, Pan Q, Hu J, Gao XD, Chcn B, Li JM, Xiong SM, Gu LJ. TangJY. LiangH, Jiang H, Xue YQ, Shen ZX, Chen Z, Chen SJ (2006): NOTCH1mutationsin T-cell acute lymphoblastic leukemia:prognostic significance and implicationin multifactorialleukemogenesis. CIin Cancer Res 12:3043-3049. Zuna J. Muzikova K, Hrusak0, Stary I, TrkaJ (2002): Significance of real-timequantitativePCR detection of p I6 gene deletions in childhood acute lymphoblastic leukemia. Haematologica 87:668469.

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CHAPTER 10 ~~

Mature B- and T-cell Neoplasms and Hodgkin Lymphoma REINER SIEBERT

Maturelymphoidneoplasmsare an extremelyheterogeneousgroupof malignancieswith regardto biological, clinical, and morphologicalfeatures(Jaffeet al., 2001). The clinical presentationmainly includes leukemic forms and tumorsaffecting predominantlylymphaticorgans,suchas the lymphnodesor spleen,ornonlymphaticorgans,suchas the skinor central nervous system. Both solid and circulatingphases are not infrequentlypresent togetherin lymphoidneoplasmsrenderingdistinctionbetween"leukemia"and "lymphoma" artificialin many cases. The naturalcourse run by the differentdiseases rangesfrom the ratherindolent, like in some types of chronic lymphocyticleukemia(CLL) or follicular lymphoma(FL),to the highly aggressive, as exemplified by Burkittlymphoma(BL). Historically, the main division of mature lymphoid neoplasms has been between Hodgkin'sdisease,nowadayscalled Hodgkinlymphoma(HL), andnon-Hodgkinlymphoma (NHL). More than 99% of HL and approximately85% of maturelymphoid neoplasms generallyderivefromlymphoidcells of the B-lineage, theremainderbeingderivedfromthe T/NK-cell lineage. Consideringthis biological and clinical heterogeneityas well as the relatively easy access to samplesfrom lymphaticmalignancies,it is not surprisingthata huge numberof chromosomalaberrationshave been describedin maturelymphoidneoplasmsandalso that many of them are nonrandomor even specific (Mitelmanet al., 2008). Since Manolovand Manolova(1972) firstdescribeda 14q-t markerchromosomein BL andZech et al. (1 976) identifiedthe markeras stemmingfrom a t(8;14)(q24;q32),the firstcharacteristictranslocationto be identifiedin a malignantlymphoma,the karyotypesof severalthousandmature lymphoid neoplasms have been made publicly available and many of the recurrent aberrationshave been molecularlycharacterized.Novel crypticchromosomalrearrangements are continuouslybeing identified using molecularcytogenetic approachessuch as fluorescencein situ hybridization(FISH) and microarray-basedtechnologies,including arraycomparativegenomic hybridization(aCGH)(for recentreviews, see Martin-Subero et al., 2003a, 2003b;Schwaenenet al., 2003;Dewaldet al., 2004;KearneyandHorsley,2005; Venturaet al., 2006; Nielanderet al., 2007; Wolff et al., 2007). The new information obtainedvia a varietyof recentlyintroducedtechnologiesis constantlyrefiningourpicture Cancer Cytogenetics. Third Edition, edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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of the chromosomeaberrationsof malignantlymphomasand chroniclymphoproliferative disorders,deepening our understandingof how molecularand chromosomalrearrangements are crucial events in tumorigenesis.

CLASSIFICATION OF MATURE LYMPHOID NEOPLASMS The identificationand characterization of recurrentchromosomalchangesin thetumorcells has influenced and continues to have a major impact on the classification of mature lymphoid neoplasms (Harriset al., 1994; Jaffe et al., 2001; Swerdlow et al., 2008). For example, mantle cell lymphoma(MCL) was only accepted as a separateentity once the translocationt( 1 1 ;14)(q13;q32) leadingto cyclin D 1 activationthroughthejuxtapositionof CCNDf to IGH was identifiedas a genetic hallmarkof this disease (Bankset al., 1992). A problemwhen assessing the many cytogenetic studies providingthe data on which this chapteris based is that most of them were performedbefore the publication and widespread acceptance of the “WHO classification of tumors of hematopoietic and lymphoid tissues” (Jaffe et al., 2001; Swerdlow et al., 2008). Thus, in many instances, the diagnosisthen given is no longerconsideredvalid or it may not even exist anymore;in fact, it is for this very reasonthatthe title of the presentchapterhas been changedfromthat of the previouseditionsof CancerCytogenetics. Usually the new classificationreflectsan increasedunderstandingof disease biology;for example,whatwas formerlycalledt(ll;l4)positive CLL or B-cell prolymphocyticleukemia (B-PLL) is today, based on modern immunophenotypinganalyses, mostly diagnosedas leukemic MCL, thoughrarecases of true t( 11;14)-positiveCLL or B-PLL might exist. In addition, the detection of novel cytogeneticcorrelationsas well as the increaseduse of new gene expressiontechnologies make revisions of the WHO classification necessary, and indeed a first update was publishedduringthe editing process of this chapter.Although the presentchapterwidely relies on the 200 1 WHO classification,it neverthelesscovers severalcytogeneticfindings integratedinto the updated WHO classification(Swerdlow et al., 2008). For example, among the diffuse large B-cell lymphomas (DLBCL), anaplastic lymphoma kinase (ALK)-positive DLBCL have been identitied based on their genetic features and the germinalcenter B-cell (GCB)-likeand activatedB-cell (ABC)-like subtypesof DLBCL are to be defined by their gene expression protiles (Alizadeh et al., 2000; Rosenwald et al., 2002; Gascoyneet al., 2003). ABC- and GCB-DLBCLshow significantlydifferent distributionsof chromosomalimbalancesdetectedby aCGH,butconventionalcytogenetic studiesusing this subgroupingdo not yet exist (Rosenwaldet al., 2002; Bea et al., 2005). The WHO classificationgroups lymphoid neoplasmsaccordingto four main criteria, namely theirclinical, morphologic,immunophenotypic,and genetic features.The relative diagnosticimportanceof these parametersdiffers among diseases;there is no one “gold standard”(Jaffeet al., 2001). For each neoplasm,a cell of origin is postulated.Often this putativecell of originrepresentsthe stageof differentiationratherthanthe cell in which the actual initial transformingevent occurred,since the latter is not known with certainty. Therefore,the classification is widely based on how we perceive normal B- and T-cell developmentsto proceed. The presentchaptermostly adheresto the recommendationsof the 2001 WHO classification(Jaffe et al., 2001) but will also includesome more recentfindingsand correlations from the revised WHO recommendations.Accordingly,the cytogenetic findings will be presentedunderthe main headingsmatureB-cell neoplasms,matureT-cell neoplasms,and

B- AND T-CELL DEVELOPMENTAND PHYSIOLOGICAL

299

Hodgkinlymphoma.For the convenienceof the reader,at the beginningof each section, a tabularcomparisonof the most importantrelevantclassificationsystems is provided.

B- AND T-CELL DEVELOPMENT AND PHYSIOLOGICAL B- AND T-CELL RECEPTOR REARRANGEMENTS The developmentand maturationof B- and T-lymphocytesare tightlyregulatedprocesses that take place in the bone marrow, peripheralblood, and lymphoid organs. Every maturationstage is characterizedby physiologicalgenetic rearrangements and expression of certainsurface molecules and cytokines (for recent reviews, see Kiipperset al., 1999; Kiippersand Dalla-Favera,2001; Kiippers,2005). The cells of the immune system are able to recognize multiple antigens through a multitude of different antigen-specificreceptors. This diversity is generated through programmedintrachromosomalrearrangementsof the genes encoding immunoglobulins (fG)in B-lymphocytesand T-cell receptors(TCR)in T-lymphocytes.These genes contain all or partof gene segmentsfor variability(V), diversity(D), joining (4, and constant( C ) sequences.Rearrangements of the V, D,and J genes areresponsiblefor the greatvariability and specificity of the immune system. immunoglobulinmolecules,also calledantigenreceptorsorantibodies,arecomposedof lg heavy chains (IgH) and light chains,eitherkappa(Iglc) or lambda(Igh).These proteins areencodedby the IGHlocus at chromosomeband 14q32, IGK at 2p 12, andIGL at 22q 1 1. ThefGH gene is composedof V, D,J, andCgenesegments(Fig. 10.1), whereasIG light-chain

(b)

VH0&

recombination

-

Class switch recombination

Somatic hypermutation

vw

chrl4 #

chrlrl -#/-

(c) chr ?

d

u

r -Hw(k/ u w

l

--4

ttw -4

1

H ' M N

der(?) ~ 1 4 )

FIGURE10.1 Schematicrepresentationof the mechanismsleading to IGH translocationsin B-cell malignancies (based on Willis and Dyer, 2000; Kuppers and Dalla-Favera,2001). (a) IGH locus , constant(C)regions. germlineconfigurationdisplayingvariable(VH),joining (.IH), diversity( D H )and Switchregions (blackand white rectangles)lie upstreamof each constantregionwith the exception of C6. Ep and E a enhancersare shown in red. (b) Schematicrepresentationof the VDJ recombination, class switch recombination,and somatic hypermutationmechanisms. (c) Formationof IGHtranslocations. Depending on the breakpoint location at 14q32, the IGH locus may deregulate protooncogenes in both partnerchromosomesthroughthe translocation(elbowed arrows). (See the color version of this figure in Color Plates section.)

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MATURE B- AND T-CELL NEOPLASMSAND HODGKIN LYMPHOMA

genes lack D segments.In the bone marrow,B-cell developmentis initiatedby rearrangementsof IGHand IGKXloci in B-cell progenitors.The so-called V(D)J in IGH(Fig. 10.1) and VJ in IGWL recombinationscreatea functionalIg. This Ig, of IgM isotype but also IgD in matureB-cells, is expressedon the surfaceof B-cells andis essentialfor cell development and survival. Those cells that produce nonfunctionalrearrangementsdie by apoptosis. B-cells leave the bone marrowto become mature,naive (not exposed to antigen)cells that travel throughthe blood streamto secondarylymphoid organssuch as the lymph nodes, spleen, and mucosa-associatedlymphoid tissue (MALT). There the B-cells that interact with antigensthroughmembrane-boundIg are clonally selected and undergoa process of proliferationand differentiationto create a germinal center.The genomic DNA is then modified by receptorediting, class switching,and somatic hypermutation(Fig. 10.1). Receptorediting is a process by which an originallyexpressedantibodypolypeptide chain, usually a light chain, is replaced by anotherone. The process is mediated by secondaryrearrangements of the variableregion segments.Some B-cells change theirIg isotypefromIgM and IgD to IgG, IgA, or IgE, a processcalled class switching(Fig. 10.1). This event is mediatedthroughfurtherrecombinationsof the IGH locus, by which DNA between switch regions immediatelyupstreamof the constantregionsis deleted. Somatic hypermutation is the processby whichmutationsareintroducedintothe variablesequences of IG genes to increasethe affinityforthe antigen(Fig. 10.1).Eventually,some of thesecells with mutantantibodiesexpressingincreasedaffinityarereleasedto the peripheralblood as antibody-secretingcells, plasmacells, or long-lived memory cells. The T-cell receptoris a heterodimercomposedof either01 and p or y and 6 chains.The genes encoding these proteinsare T C W D locatedat 14ql1, TCRBat 7q34, and TCRGat 7p 14. The processby which thesegenes areassembledto makea functionalT-cell receptor is similarto that occurringat IG loci in B-cells. However, in contrastto B-lymphocytes, T-1ymphocytesproliferateanddifferentiatealongseveraldifferentdevelopmentalpathways generatingdistinctsubpopulationsof matureT-cells.

CHROMOSOMAL TRANSLOCATIONSINVOLVING IG AND TCR LOCI The IG loci, includingboththe IGH locus in 14q32and the IGKandIGLlight-chainloci in 2p 12 and22q I 1,respectively,arerecurrentlyinvolvedin manychromosomaltranslocations in matureB-cell malignancies(Table 10.1). In contrast,the TCR loci are ratherseldom involved in structuralaberrationsin matureT-cell neoplasmswith the notableexceptionof T-cell prolymphocyticleukemia(T-PLL),in which inv( 14)(qllq32)andits variantt(14;14) (41l;q32)arepresentin approximately80%,with some of the remainingcases showingthe rarebut recurrentt(X;14)(q28;q1 1) (discussedbelow). Thefrequencyof IG translocationsin differentsubtypesof matureB-cell malignanciesis quitevariable.Forsome diseases,like BL with its t(8;14)(q24;q32)and light-chainvariants or MCL with its t(ZZ:14)(q13;q32),one or a group of distinct IG translocationsare pathognomonicfor the disease and, hence, detectable in more than 95% of all cases (Fuet al., 2005; Hummelet al., 2006). In otherinstances,like DLBCLor multiplemyeloma (MM), IG translocationsare detectablein roughlyhalf of the cases but recombiningwith a largenumberof partners(Siebertet al., 2001 ;KuehlandBergsagel,2002; Lenzet al., 2007). At the otherend of the spectrum,CLLis notablefor its lack of IG translocationsand when breaks do occur at 14q32 in this disease, they do not always involve the IGH locus (Nowakowskiet al., 2005; Wlodarskaet al., 2007). IG translocationsin malignantB-cells

CHROMOSOMALTRANSLOCATIONS INVOLVING IG AND TCR LOCI

301

TABLE 10.1 Chromosomal Translocations and Other Structural Aberrations Affecting the ZGH Locus in 14q32,the IGK Locus in 2p12, or the ZGL Locus in 22qll in Mature B-Cell Malignancies Other Than Multiple Myeloma Translocation

LymphomaLeukemia Subtype

Translocation Partner

t( 1 ;14)(p22;q32Y

MALT lymphoma

BCLIO

t(1;14)(q21;32)

Diffuse large B-cell lymphoma Follicularlymphoma B-CLL, immunocytoma MALT lymphoma,diffuse large B-cell lymphoma Diffuse large B-cell lymphoma Diffuse large B-cell lymphoma,otherB-cell lymphoma Splenic lymphomawith villous lymphocytes Burkittlymphoma/leukemia, diffuse large B-cell lymphoma.B-cell prolymphocyticleukemia, multiplemyeloma Lymphoplasmocy toid immunocytoma, otherB-NHL Diffuse large B-cell lymphoma Mantle cell lymphoma,B-cell chronic lymphocytic leukemia,B-cell prolymphocyticleukemia, splenic lymphomawith villous lymphocytes PrimarymediastinalB-cell lymphoma Diffuse large B-cell lymphoma Mantlecell lymphoma

MUCl

BurkittlymphomaAeukemia. multiplemyeloma Chroniclymphocytic leukemia.low-grade B-NHL Diffuse large B-cell lymphoma Follicularlymphoma,diffuse large B-cell lymphoma

BCL7A

t( 1;22)(q21 ;q1 I )

t(2;14)(pI3;q32) t(3;14)(pl4;q32) t(3;14)(q27;q32)' t(6:14)(p21 ;q32)'

t(7;14)(q2I ;q32)' t(8;14)(q24;q32)'

t(9; 14)(p13;q32)

t( 1 I :14)(q23;q32) t(l I; 14)(q23;q32) t(12;14)(pl3:q32)u t(l2; 14)(q24;q32) del( 14)(q24q32)

t( 14;15)(q32;

qll-13) t( 14;18)(q32;q2

FCGR2B BCLIIA FOXPI

Reference Willis et al., 1999; Zhang et al., 1999 Dyomin el al., 2000, Gilles et al., 2000 Callananet al., 2000 Sattenvhiteet al., 2001 Streubelet al., 2005

CCND3

Kerckaertet al., 1993; Ye et al.. 1993a Sonoki et al., 2001

CDK6

Corcoranet al., 1999

MYC

Taubet al.. 1982

PAX5

Busslingeret al.. 1996; Iida et al., 1996

NFKBZ ( L f l l O )

Nen et al.. 1991

CCNDl (BCLI )

Motokurael al.. 1991: Rosenberget al., 1991

PAFAHIAZ

Lecointeet al., 1999

RCK

Aka0 et al.. 1992

CCND2

Gesk et al., 2006; Herens el al., 2008 Zani et al., 1996

BCL6

ZFP36Ll

BCL8

Pospisilovaet al., 2007; Nagel et al., in preparation Dyomin et al., 1997

BCL2

Tsujimotoet a]., 1985

(contimed)

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MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

TABLE 10.1 (Continued) LymphomanRukemia Subtype

Translocation

Translocation Partner

Reference

t( 14;18)(q32:q21)

Marginal zone lymphoma

iVlALT1

t( 14;19)(q32;q 12) t(14; 19)(q32;q13) t( 14;19)(q32;q 13)"

Diffuse large B-cell lymphoma Diffuse large B-cell lymphoma B-cell chronic lymphocytic leukemia, other B-NHL Low-grade B-NHL

CCNEI SPIB BCW

Sanc her-lzquierdo et al., 2003; Streubel et al., 2003 Nagel et al., in preparation Lenz el al., 2007 Ohno et al., 1990

IGL ?

Aamot et al., 2005a

t( 14;22)(q32;q I

I)

Modified from Willis and Dyer (2000) and Siebert et al. (2001 ). Only those translocations are shown in which the partner genes have been identified by rnolecularcloning.Several other 1C translocations have been identified and in part FISH mapped, like t(14;19)(q32:pI3)(Micci et al.. 2007). but await unambiguous identification of the partners. "Variants with 1G light-chain loci in 2p12 and 22qll have been described.

may be multipleand may involvebothIGHand a light-chainlocus. A commoncombination is thatof a t(14;18)(q32;q21)in FL being followed by a t(8;14) or a correspondingt(2;8)or t(8;22) variant at transformationto DLBCL (Knezevich et al., 2005; Martin-Subero et al., 2005). Such cases are usually clinically aggressive and respond poorly to chemotherapy.The latterexample also shows that hardlyany of the IG translocationsin mature B-cell neoplasms is completely specific for a certain lymphomasubtype.For example, t( I I ;14)(q13;q32)is recurrentin both MCL and MM and t( 14;18)(q32;q21)is recurrentin both FL and DLBCL but also recurrentlyoccurs, in additionto trisomy 12, in CLL. The t(8;I4)(q24;q32)and its variantscan occur,besidesin BL, in almostany kindof matureB-cell neoplasm, includingCLL, MCL, FL, and DLBCL (Karsanet al., 1993; Au et al., 1999, 2000; 2004; Sen et al., 2002; Majid et al., 2007). ChromosomaltranslocationsaffectingIG loci thatlook identicalat the cytogeneticlevel arealso often identicalin termsof which genes they target.In contrast,sometimesdifferent partnergenes are involved in seemingly identicaltranslocations,like BCL2 and MALTI, which recombinewith IGH in t( 14;18)(q32;q21) in FL andMALTlymphoma,respectively (Tsujimotoet al., 1985; Sanchez-lzquierdoet al., 2003; Streubelet al., 2003). As outlined above, all IG loci are subject to multiple physiologicalbreaksas partof recombinationevents during B-cell development.Chromosomaltranslocationsare supposed to derive from mistakes in these recombinationprocesses. Depending on whether mistakesoccur in the V(D)J joining process, duringclass switchingor as by-productsof somatichypermutation,the chromosomalbreakpointsarefound in differentregionsof the 1G loci (Fig. 10.1). Withregardto the heavy-chainlocus, class switch-associatedtranslocationsaffectthe centromericpartof ZGH in I4q32containingthesegmentsforthe constantIg regions, VDJ-associatedtranslocationsmostly affect the middlepartof ZCH thatcontains the J-segments,and somatichypermutation-associated translocationspredominantlyaffect the telomeric part of the IGH locus containingthe V-segments (Willis and Dyer, 2000; Kiippersand Dalla-Favera,2001 ;Kuehl and Bergsagel,2002; Dyer, 2003; Kuppers,2005). The locationof the IG breakpointis supposedto reflectthe developmentalstageat which the translocationoccurs in a B-cell. In line with this hypothesis, the t( 1 1 ;14)(q13;q32) of MCL, which is supposed to occur in a pregerminalcenter cell in the bone marrow throughan unsuccessful VDJ rearrangement,mostly involves a J-segment.In contrast, the cytogenetically identical translocationin MM usually stems from a failed class

CHROMOSOMALTRANSLOCATIONS INVOLVING IG AND TCR LOCI

303

switch recombination event supposed to take place in or after the germinal center and affects the region containing the constant genes. Similarly, IG translocationsin FL are supposed to derive from mistakes in the VDJ-recombinationprocess whereas those occurring in DLBCL, MM, or CLL mostly involve class switch regions (Willis and Dyer, 2000; Kiippersand Dalla-Favera,2001 ; Kuehl and Bergsagel, 2002; Dyer, 2003; Kuppers,2005). Remarkably,the t(8;14)(q24;q32) in endemic BL mostly involves the J, whereas the same translocation in sporadic BL mostly affects a constant region, indicating that different pathogenetic mechanisms are at work in the two situations (reviewed in Boxer and Dang, 2001; Kuppersand Dalla-Favera, 2001). The consequences of the IG translocationsare activationof intact oncogenes through deregulationmediatedby enhancersegmentswithinthe IG loci. Only on rareoccasions are fusion transcriptsof the IG and oncogenes generated(Willis and Dyer, 2000). Although VDJ-associatedtranslocationsof the IGH locus lead to activationof the oncogene on the der(14) throughjuxtaposition of the translocatedoncogene with the IGH enhancer, class switch translocationsin principlecan activateoncogenes on both derivativechromosomes because the centromericIGH enhancer(s)remain on der(14) whereas the telomeric IGH enhancer(s)translocateto the derivativepartnerchromosome(Fig. 10.1).This explainswhy recurrentloss of the der(I I)t(11;14) in MCL or der(14)t(4;14) in MM does not affect deregulationof the CCNDI and MMSETgenes in 1 lq13 and 4p16, respectively (Santra et al., 2003). In translocationsaffecting the IGK and IGL light-chainloci, the oncogenic activationusuallytakesplace on the derivativepartnerchromosomesto which the enhancer elementswere translocated(Willis and Dyer, 2000; KiippersandDalla-Favera,2001 ;Kuehl and Bergsagel, 2002; Dyer, 2003; Kiippers,2005). The breakpointon the derivative partnerchromosome can be located 3’ or 5’ of the targetoncogene because the transformingmechanismis deregulatedexpression through aberrantjuxtaposition with the IG enhancer rather than creation of a gene fusion or promoter substitution. Enhancers can exert their activity over distances of several hundred kilobases. In BL, for example, the breakpointsaffecting the MYC gene can be located up to almost 1 Mb centromericof MYC in t(8;14) and telomeric of MYC in t(8;22) and t(2;8) (Joos et al., 1992a, 1992b: Einerson et al., 2006). Remarkably,the breakpointsof the t(8; 14) in 8q24 vary between endemic and sporadicBurkitt lymphomas with the former more frequentlyaffecting the far 5’ (centromeric)partof the MYC locus (reviewed in Boxer and Dang, 2001; Kiippers and Dalla-Favera, 2001). This variability of the breakpoints, which can also be observed in MYC translocations affecting non-IC loci, can pose considerable diagnostic problems if FISH is applied for their detection. Gene deregulation may occasionally be a consequence of an insertion ratherthan a translocation.Thus, bothBCL2 and CCNDI have been observedto be insertedinto the IGH locus in cases of follicularlymphomaand MCL in rearrangementsthatfunctionallymimic the t(14;18) and t(ll;l4), respectively (Vaandrageret al., 2000; Fenton et al., 2004). Althoughthe biological consequencesof such insertionsappearto be identicalto those of regulartranslocations,their pathogeneticorigins would appearto involve differentDNA breaks. Exceptions to the general rule that the recurrenttranslocationsof mature lymphoid neoplasmsrarely give rise to fusion genes occur predominantlyin MALT lymphomaand T-cell lymphomas. In the former, the specific t(l1;18)(q2I;q2/) leads to API2-MALT1 fusion (Akagi et al., 1999; Dierlammet al., 1999). In the latter,t(2;5)(p23;q35) as well as its rarevariantslead to fusion of the anaplasticlymphomakinase(ALK)gene in 2p23 with the

304

MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

nucleophosmin(NPM) gene or, in the case of variants,otherpartners(Morriset al., 1994). Finally,rarecases of peripheralT-cell lymphomawith an ITK-SYK fusion due to a t(5;9) (q33;q22)have been reported(Streubelet al., 2006b). The mostcommonrearrangement of a non-1Glocus in maturelymphoidneoplasmsis the targetingof the BCM gene in 3q27 that takes place in a varietyof translocationswith a multitudeof chromosomalpartners(Table10.2). Commonto all these translocationsis that they lead to promotor substitutionand, consequently, deregulationof the BCL6 gene (Ohno, 2004, 2006; Jardinet al., 2007). Other oncogenes known to be targets of IG translocationsare sometimesjuxtaposeddirectlynext to each otherthroughtranslocations, such as PAX5 and MYC througha t(8;9)(q24;p13)and BCU andMYC throught(3;8)(q27; q24) in t( 14;18)-positiveFL. (Bertrandet al., 2007; Sonoki et al., 2007). How the supposed MYC deregulationin these translocationsoccurs is so far unknown though an enhancer mechanism seems likely. There is no evidence for interpositionof IG sequences like in t(8;14; 18)(q24;q32;q21),a recurrentaberrationin FL progression,in which bothMYC and BCL2 are deregulatedfrom a common IG fragmentbetween them (Dyer et al., 19%; Knezevich et al., 2005).

TABLE 10.2 Chromosomal Translocations Affecting the BCM Locus in 3q27 in Mature B-Cell Neoplasms (Modified from http://atlasgeneticsoncology.org/Genes/BCL6IDZO. html) Translocation

Band of PartnerLocus

B C U PartnerGene

t(2;3Mp12q27) t(3;3,lq25;y?7) t(3;3)(q27;q27) t(3:3&27;q27) t(3;3)(q27;q29) t(3;4)(q27;pl3) t(3:6)(q27;p22) t(3;6)(q27;p21) t(3;6)(q27;p21) t(3:6)(q27;p2I ) t(3:6)(q27;p 12) t(3;6)(q27;q15) t(3;7)(q27:p12) t(3:8)(q27:q24.I ) t(3;9)(q27;plI) t(3:l l)(q27;q23) t(3:12)(q27;p13) t(3;12)(q27;q12) t(3;I2)(q27:q23) t(3;13)(q27;q14) t(3;14)(q27;q32) t(3;14)(q27;q32) t(3;16)(q27;p13) t(3: I6Kq27:p1 1 ) t(3: I9)(q27;q13)

2pl2 3q25 3q27 3q27 3q29 4p13 6p22 6p2 I 6p2I 6p21 6p12 6q15 7p12 8q24.1 9pl I I lq23 12p13 12q12 12q23 13q14 I4q.12 14q.32 16~13 16pl I 19q13

lGK MBNLl ST6GALl ElF4A2 TFRC

RHOH HISTl H41 PIM I 5fr53

H4 cluster 1 HSPWABI SNHGS

IKZFI MYC GRHPR POU2AFI GAPDH LRMP NACA LCPl IGH HSPWAA I CNTA 1121r

NAPA

CYTOGENETICEVOLUTIONIN LYMPHOIDNEOPLASMS

305

CYTOGENETIC EVOLUTION IN LYMPHOID NEOPLASMS Severalcytogeneticand subsequentmoleculargenetic studieshave led to the conceptthat the neoplasticprocess in many maturelymphoid malignanciesfollows a multistepmodel similarto that proposed for colorectalcancer and some other malignancies.It is widely assumed that a primarygenetic alterationof a tumor clone initiates lymphomagenesis. Primaryalterationsareusuallypresentin the stemlineof a tumor.Chromosomaltranslocations, like several of the IG and TCR translocations,are most common as primarygenetic alterationsand can serve as valuablediagnosticmarkers.However,it should be noted that what in one disease setting may constitutea primarychange, in anothermay occur as a secondaryabnormality. As shown in mouse transgenic models, the primarygenetic alterationis often not sufficientto drive lymphomagenesis(reviewedin Willis and Dyer, 2000). Moreover,by sensitivemoleculartechniques,several primarygenetic alterationslike t( 14;I S), t( 1 1 ;14), or t(2;5) can also be detected in healthy individuals,sometimes at surprisinglyhigh levels (Maes et al., 2001 ;BLecke et al., 2002; Biagi and Seymour, 2002). We do not know whether the cells then carrying the translocationsare susceptible to neoplastic transformation,but neverthelesssuch findings have contributedto the view that additional genetic changes are required for the full neoplastic phenotype of a mature lymphoid malignancyto emerge. These aberrationsare usually called secondarygenetic changes. Consequently,the vast majorityof lymphomaswith a defined primarychange, like t( 14;18)-positive F l or t( 11;14)-positive MCL, carry also secondary alterations (Johansson et al., 1995). The so-called tertiary genetic events may occur in some lymphomasand are associated with the transformationof an indolent malignancy to more aggressive forms. As will be described subsequently, secondary and tertiary chromosomalalterationsin lymphoid malignanciespredominantlylead to gain or loss of genetic material,whereas recurrent,balanced translocations-with the exception of translocationsaffecting the MYC locus in chromosomeband 8q24-seem to be uncommon as secondaryevents. The numberof secondarygenetic aberrationsusually increases duringdisease progression.As a rule of thumb, within a given lymphomasubtype,the prognosis is inversely related to the complexity of the karyotypeor the extent of the secondarychanges. Secondary genetic aberrationsmay be present in only a subset of cells of a given tumor and different secondary aberrationsmay be present in different subclones. Tumors of the same type (and harboringthe same primary event) might thus show variation in terms of secondary aberrations. Nevertheless, the pattern of secondary changes in mature lymphoid neoplasms is not random, but rather seems to depend on the nature of the primaryevent. Some primary genetic alterationslike t( 1 1 ;18)(q21;q21) are hardly ever associatedwith cytogeneticallydetectablesecondary aberrations (Horsman et al., 1992; Ott et al., 1997b; Barth et al., 2001). Other translocationssuch as t(1;14)(p22;q32) are associated with a highly conserved set of secondary events, including trisomy of chromosomes 3, 12, and 18 (Siebert et al., unpublished).FL with t( 14;18)(q32;q21) show different,distinctivepatternsof secondary changes suggesting different pathways of germinal center B-cell transformation (Hoglund et al., 2004). T-cell prolymphocyticleukemia is characterizedby an extraordinaryconservationof both primaryand secondarygenetic changes (reviewedby Dung et al., 2007).

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MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

CHROMOSOMAL ABERRATIONS COMMON TO MULTIPLE SUBTYPES OF MATURE LYMPHOID NEOPLASMS In the following sections, the most common cytogenetic changes in maturelymphoid neoplasmswill be discussedin the contextof the disease subtypesin which they are most prominent.It should neverthelessbe emphasizedthat many aberrationsare recurrentin severalor even all kinds of maturelymphoidneoplasms.These might constituteprimary aberrationsin some of them butaremorelikely to be secondaryoreven tertiaryaberrations in the majority.Probablythe best exampleof such a low-specific changeis deletionof 6q. Deletions of the long arm of chromosome 6 arefrequentin all types of maturelymphoid neoplasmsincludingHL. The incidencein differentstudiesvariesfromroughly5 % in CLL to 30%in DLBCLup to even higherfrequenciesin T-/NK-celldisorders.Thedeletionshave mostly been interpretedas terminal.Band 6q21 seems to be the one most often affected. Offit et al. (1993) reviewed the chromosome 6 abnormalitiesin 459 consecutively ascertainedkaryotypicallyabnormalcases of NHL and suggested that three minimally commondeletedregionscould be discerned:a distalone encompassing6q25-27, a second one involvingthe moreproximalband6q21, whereasthe thirdwas locatedbetweenthe two others,involving band6q23. Severalloss of heterozygosity(LOH),molecularcytogenetic, and aCGHstudieshave meanwhilenarroweddown criticalregions in 6q to 6q2I, 6q23.3, and6q27. These studieshave identifiedrecurrentinactivationof thePRDMUBLIMPI gene in 6q2 1 in ABC-DLBCL(Pasqualucciet al., 2006; Tamet al., 2006). Moreover,a minimally commondeletedregion in 6q23.3 containingthe TNFAIP3 (A20) andPERPgenes hasbeen identifiedin FL and ocularadnexalmarginalzone B-cell lymphoma(MZL),and mutations inactivatingTNFAIP3 have been detected in classical Hodgkin lymphoma (cHL) and primarymediastinalB-cell lymphomas(PMBCL)(Ross et al., 2007; Giefing et al., 2008; Honma et al., 2008; Schmitz et al., in preparation). The descriptionsin this chapterwill focus on chromosomalchangesas they aredetected by chromosomebandingtechniques.It needs to be stressedthat the "real" frequenciesof chromosomalaberrationsmay be underestimatedif this approachis the only one taken, withouthelp frommolecularcytogenetictechniqueslike FISH andCGH,which can also be used to examine paraffin-embeddedsamples.Therefore,thoughthe contributionof these techniquesis not the primeconcernof this book, datathusobtainedwill oftenbe referredto as they havecontributedmightilyto thecurrentpictureof the cytogeneticchangesof mature lymphoid neoplasms. For reviews focusing on the applicationof ElSH and CGH in lymphoid neoplasms, the reader may be well advised to consult Martin-Subero et al. (2003a), Dewald et al. (2004), Kearneyand Horsley (2005), Venturaet al. (2006), and Wolff et al. (2007). Finally,the exponentiallygrowing numberof studiesusing aCGH andsingle nucleotidepolymorphism(SNP)chip-basedtechnologieswill not be discussedin detailhere.A recentreviewof the findingsobtainedusing these technologieswas published by Nielanderet al. (2007) and databasingof the findingshas been initiated(http://www. progenetix.net/).

MATURE 6-CELL NEOPLASMS A comparativeoverviewof thedifferentsubtypesof matureB-cell neoplasmsrecognizedby the Kiel, REAL, and WHO classificationsis providedin Table 10.3. The clinically most relevantchromosomalaberrationsare summarizedin Table 10.4.

TABLE 10.3 Comparisonof the Kiel, REAL, and WHO Classificationsof B-Cell Malignancies(Lennertet al., 1975; Harriset al., 1994 Jaffe et al., 2001) Kiel Classification ~~

REAL Classification

WHO Classification

~

Peripheral B-Cell Neoplasms

Mature(Peripheral)B-Cell Neoplasms

B-lymphocytic,B-CLL, B-PLL Lymphoplasmac ytoid immunocytoma

B-CLLIB-PLUsmall lymphocyticlymphoma VariantB-CLL: with plasmacytoiddifferentiation

Lymphoplasmacy tic immunocytoma Centrocytic Centroblastic,centrocytoid subtype Centroblastic-centrocytic, follicular Centroblastic-centytic, diffuse Centroblastic,follicular

Lyinphoplasmocytoid lymphoma

B-CLL/smalllymphocytic lymphoma VariantB-CLL: with monoclonal gammopathy/plasmac ytoid differentiation B-PLL Lymphoplasmocytoidlymphoma

Monocytoidlymphoma, including marginal zone lymphoma

Hairy cell leukemia Plasmacytic Centroblastic (monomorphic, polymorphicand rnultilobatedsubtypes)

Mantlecell lymphoma

Mantlecell lymphoma Variant:blastoid

Follicularcenter lymphoma, folliculargrades1 and I1 Follicularcenterlymphoma, diffuse, small cell" Follicularcenterlymphoma, folliculargradeIII

Follicular lymphoma, gradesI and I1

Extranodalmarginalzone B-cell lymphoma(low-gradeB-cell lymphomaor MALT) Nodal marginalzone B-cell I y mphoma" Splenic marginalzone B-cell lymphoma" Hairy cell leukemia Plasmocytomahyeloma Diffuse large B-cell lymphoma

Follicularlymphoma,grade 111 Cutaneousfollicle center lymphoma Extranodalmarginal zone B-cell lymphomaof MALT type Nodal marginalzone B-cell I y mphoma" Splenic marginalzone B-cell lymphomaa Hairy cell leukemia Plasma cell myeloma/ plasmorytoma Diffuse large B-cell lymphoma, variants:centroblastic, immunoblastic,T-cellhistiocyte rich, lymphomatoid granulomatosistype. anaplastic large B-cell, plasmablastic

B-immunoblastic B-large cell anaplastic lymphoma

Primary mediastinallarge 6-cell 1ymphoma

Burkittlymphoma

Burkittlymphoma High-gradeB-cell lymphoma, Burkitt-like"

Subtypes:mediastinal(thymic) large B-cell, primaryeffusion lymphoma,intravascularlarge B-cell lymphoma Burkittlymphoma Burkittcell leukemia Atypical Burkittlymphoma

-~

~

Bold letters repEsent the most common subtypes. uProvisionalentity.

308

MATURE 6-AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

TABLE 10.4 Overview of Frequent and Diagnostically Relevant Chromosomal Aberrations in the Most Common Mature B-Lymphoid Neoplasms ______~

Neoplasm

Cytogenetic Aberration

B-cell chronic lymphocytic leukemiahmalllymphocytic lymphoma

del( 13q) 12 del( I Iq) del(6q), deU 17p) t/der(14)(q32) t(1 1;14)(q13;q32) del( I Iq). del( 13q). der(.3q) t 12, del(1p). del(6q), del(9p). del( I7p) t(l I ;IS)(q21;q21) t(14;18)(q32;q21)involving MALT1 t(3;14)(p14;q32) t( 1; 14)(p22;q32) 3/3q, t 18/18q t( 14; 18)(q32;q2I) and variants involving BCL2 t(3q27)

Mantle cell lymphoma

Extranodalmarginalzone B-cell lymphomaof MALT type

+

+

Follicularlymphoma

+X, +7, +lU12q, +18/18q,

Diffuse large B-cell lymphoma

+der( I8)t( 14;18). del(6q),del (1Oq).del(l7p), dup(lq),der(Ip) t(3q27) t( 14;18)fq32;q2I ) t(8; 14)(q24:32)/t(Sq24) t 3/3q, + 1811Sq, 19q, del(6q). del(9p) +Iq, +2p13-16, t7. +lIq, +12/12q +9/9~23-24, +2p13-16 t(8;14)(q24:q32)and variants duP(lq) +7, $12 t(4;14)(pl6;q32), t(l 1;14) (q13;q32). t( 14:16)(q32;q23) t(6; 14)(p2S;q32), t(8;14)(q24;q32) Other t( I4q32) - 13,del(13q) dup(I q),del(6q), del( 1 1 q)

+

Burkittlymphoma

Plasma cell myelomal plasmocytoma

%

40% -15%

15-20% -5% 420% >95% 1&SO% 5-15% 15% 11%
< 10%(FL1/2)-55% W3b) > 10% 2040% 20-30% (GCB) 5-10% 1040%(ABC) 1 W O % (GCB) 50-90% (PMBCL) 100% ~30-50% 1 &30% -206

-

5%

15-50% 5-20%

MATURE 6-CELL NEOPLASMS

309

Chronic Lymphocytic LeukemialSmall Lymphocytic Lymphoma, B-Cell Prolymphocytic Leukemia Chroniclymphocyticleukemiaand its nodal variant,small lymphocyticlymphoma(CLL/ SLL,here covered togetherunderthe acronymCLL),accountfor 7% of all B- and TNKcell lymphomas.A variantof CLL is Mu heavy-chaindisease (Jaffeet al., 2001). B-cell prolymphocyticleukemia is an extremelyraredisease ( 1% of lymphocyticleukemias)in which prolymphocytesexceed 55%of lymphoidcells in the blood. CLL/SLL(including variant CLL) and B-PLL are distinct entities within the WHO classification (Jaffe et al., 2001). Nevertheless,from the cytogenetic point of view, since these two diseases show considerableoverlap,they are discussed togetherhere. Chromosomeaberrationscan be detectedin morethan80%of CLWB-PLLcases studied afterappropriatestimulation(Dickeret al., 2006; Mayret al., 2006; Haferlachet al., 2007). The differentfrequenciesof abnormalclones that have been reportedin CLWB-PLLare attributableto differencesin disease stage, treatment,and cultureconditions,as well as to which mitogens were used by the various investigators. The neoplasticcells of CLL (and, to a somewhatless extent,of B-PLL) have very low spontaneousmitoticactivityand theirresponseto conventionalmitogensis poor.In earlier studies,40-50% of CLL showed clonal chromosomeaberrationsand common recurrent abnormalitiessuch as trisomy 12, del(l3q), del(llq), and del(l7p) could be identified (reviewed by Dohner et al., 1997a, 1997b, 1999; Stilgenbaueret al., 2000). Interphase cytogenetic studies using CGH and locus-specific FISH probes showed that the true incidencesof chromosomalaberrationsin CLL differedfrom what was seen by chromosome bandinganalysis(Dohneret al., 1993, 1997a, 1997b;Stilgenbaueret al., 1993; Bentz et al., 1995). On the one hand, the percentageof cases showing aberrationsat all was significantly higher using interphasecytogenetics (>go%), mostly due to the lack of aberrantmetaphasesidentified by banding analysis and the presence of cytogenetically crypticdeletions. On the other hand,the relativeproportionof CLL with trisomy 12 was higher and of deletions was lower by conventionalcytogeneticsthan by interphaseFISH. Again, this might reflectproliferationadvantagesor disadvantagesof the aberrantclone as well as the fact that some of the deletions are cryptic(Stocker0et al., 2006). Particularly pronouncedwas thisdifferencefordel( 13q),whichcan be detectedin approximatelyhalf of all CLLby FISH butonly in some 10%by bandingcytogenetics(Stilgenbaueret al., 2000). The recent introductionof new mitogenic agents, CD4OL and, probablymost importantly, immunostimulatoryCpG-oligonucleotide DSP30 and IL-2, has dramatically improvedthe figures(Buhmannet al., 2002; Dickeret al., 2006; Mayret al., 2006; Haferlach et al., 2007). In a study of 506 CLL samples comparingRSH and conventionalbanding analysis, 500 cases (99%) were successfully stimulated for metaphase generation (Haferlachet al., 2007). Aberrationswere detectedin 415 of 500 (83%)cases by banding cytogenetics and in 392 of 500 (78%) cases by FISH. Whereas chromosomebanding analysisdetected832 abnormalities,FISHdetectedonly 502, demonstratingthatthe latter approachunderestimatesthe cytogeneticcomplexityof CLL(Haferlachet al., 2007). This study confirmed that CLL is characterizedmainly by genomic imbalances and that reciprocaltranslocationsare rare. A subgroupof CLL with complex aberrantkaryotype (1 6%) was identified.Mayret al. (2006), using last-generationmitogenstimulation,found translocationsin 33 of 96 (34%) CLL. The majorityof the chromosomaltranslocations occurredwithincomplexkaryotypesandwere unbalanced.A similarconclusionwas drawn also by Van Den Neste et al. (2007) who detectedtranslocationsin 42%of CLLwith 73%of

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MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

them being unbalanced.Patientswith translocationspresentedwith more complex karyotypes ( P < 0.00 I 1. It hasto be stressedthatthechromosomaltranslocationsin CLLseem to be quiteheterogenous.A commonthemeis neverthelessthatmanybreakpointsarelocated in regions showing recurrentloss in CLL, like 13q14, and are associatedwith microdeletions (Herholzet al., 2007). Particularlyin CLL with complex karyotypes,translocations often leadto loss of the TP53 locus in 1 7 ~ 1 3vice ; versa,complexkaryotypesareassociated with 17p abnormalitiesand TP53 mutations(Fink et al., 2006). Although trisomy 12, del(l3q), del(1 Is),and del(l7p), the majoraberrationsin CLL (Fig. 10.2), mostly are seen independentlyof one another,anycombinationof the fourmay on occasion be detected. Moreover,del( 1 Iq) and del( 17p) are recurrentlyobserved as secondarychanges that occur duringdisease progression. Trisomy 12 is the most frequentlyreportedchromosomeabnormalityin CLLbased on chromosome banding analysis, where it has been detected in nearly one-third of all cytogeneticallyabnormalcases. By HSH, around15% of all CLLshow trisomy 12. Partial trisomy 12canbe detectedin I0-20% of cases (Dahneret al., 1993)anda minimalcommon gained region has been confinedto 12ql3 (Dierlammet al., 1997;Schwaenenet al., 2004). Some cases with trisomy 12 also haveotherchromosomalaberrations.Amongthe recurrent additionalchanges are t( 14; 19)(q32;413) leading to IGH-BCW fusion (Marth-Subero et al., 2007), t(14;18)(q32;q21)leading to IGH-BCL2 fusion (Karsanet al., 1993; Sen et al., 2002), anda del( 14)(q24q32)with one breakpointin the IGHlocus(Tilly et al., 1988; Pospisilovaet al., 2007) (Figs 10.3 and 10.4). Moreover,lrisomy 19 andortrisomy 18 can be seen in a subset of cases (Schwaenenet al., 2004; Sellmannet al., 2007). It is unknown whethertrisomy 12 in those cases thathave additionalchangesis the primaryor secondary abnormality;there are data supportingboth views. Trisomy 12 has sometimes been associated with atypical morphologythat may resemblemantle cell lymphoma(Dohner et al., 1999; Matuteset al., 1999; Athanasiadouet al., 2006; Fink et al., 2006).

R FIGURE 10.2 Recurrent chromosomal aberrations in CLL and related lymphoid neoplasms, Fluorescence R-banding. (a) Metaphasewith trisomy 12. (b) Ideogram and partial kafyotype showing del( 1 I )(q14q23). (c) Ideogram and partial karyotype showing del( 13)(q13q33).

.

n 14 de1(14)(q21q32)

14

t l 19

t(14;19)(q32;q13)

FIGURE 10.3 Recurrent chromosomal aberrationsin CLL and related lymphoid neoplasms. Fluorescence R-banding. (a) Ideogram and partial karyotype with interstitial deletion in 14q cytogenetically assigned to 14q21q32. (b) Ideogram and partialkaryotype showing t( 14; 19)(q32; q13) involving IGHand BCL3.

P -D

-b

3

14

18

11

14

t(l1;14)(ql3;q32)

FIGURE10.4 Translocationst( 14;18)(q32;q21) and t( 11; 14)(q13;q32). Fluorescence R-banding. (a) Ideogramandpartialkaryotypewith t( 14; IS)(q32;q2I) involvingIGH andBCL2. (b) Ideogramand pmial karyotypewith t( 1 1; 14xq 13;q32) involving IGH and CCNDJ.

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MATURE 8- AND T-CELL NEOPLASMS AND HODGKlN LYMPHOMA

Structural abnormalities of 13q. t/del(l3q), are found in approximately20% of all cytogeneticallyabnormalcases (Stilgenbaueret al., 2000; Stocker0et al., 2006; Herholz et al., 2007). By FISH,the deletionis detectablein 50%of CLL (Dohneret al., 2000). The deletionstargetthe band 13q14 and severalnon-overlappingminimalregionsof loss have been described,but the RBI gene seems to be outside the critical region (Stilgenbauer et al., 1995;Migliazzaet al., 2001; Wolf et al., 2001; Ouilletteet al., 2008). FISH analyses usually apply probes spanningthe markersD13825, D13S319, or D13S272 and have detectedbialleliclosses in 13q14 in a considerablenumberof cases. Moleculartargetsof the deletionsmight be the noncodinggenes miR-15, miR16, DLEUl/BCMS, or DLEU2 (Wolf et al., 2001; Calin et al., 2002). Deletions of Ilq, with a minimalregion of loss in 1 lq22, have in earlierstudiesbeen detected in only 5%of the cases. The deletions are usually small and interstitial,del(11) (q21-22q22-23). By FISH,thesedeletionscan be detectedin 15-20%. Most deletionslead to loss of the ATM gene, which shows mutationof the second allele in a sizable subset (Dohneret al., 1997b. 2000; Schaffneret al., 1999; Austen et al., 2007). Notably, a few deletionsdo not encompasstheATM gene butinsteadaffectthe closely telomericFDX locus (Stilgenbaueret al., 1996). Structural abnormalities of 17p, t/del(l7p), are found in approximately5% of all cytogeneticallyabnormalCLL,especially in complex karyotypes(Finket al., 2006; Mayr et al., 2006). By FISH using a probe for the TP53 gene, the deletion is found in 5-10% and mutationsof the second allele can be detected in a subset of these cases (Dohner et al., 2000). In B-PLL, the frequencyof TP53 alterationsappearsto be much higher, perhapshalf of the cases. Dependingon the strictnessof the diagnosticcriteria,includingwhetherchromosome alterationsare used to make a diagnosis, the percentageof translocations targeting the IC loci in CLLB-PLL,that is, t( 14q32) and the two variantst(2p12) and t(22q1l), has variedbetweena few percentandup to 20%(Dohneret al., 2000 Nowakowskiet al., 2005; Nelson et al., 2007). The translocationt(l1;14)(q13;q32)leadingto IGH-CCNDI recombinationhas been reportedto be presentin 20%of B-PLLand somewhatless commonlyin CLL (Fig. 10.4).Today,however,most of these cases would be diagnosedas MCLthough rarecases o f t (1 1;14)-positiveCLL/B-PLLmight exist. The extent of secondarychromosomal aberrationsin these cases of t(l1;14)-positiveCLWB-PLLmight be lower than in MCLandtheprognosisbetter,althoughthisis notyet firmlyestablished.t(14;19)(q32;ql3), often associated with trisomy 12, is a recurrenttranslocationin CLL but also occurs in many other B-cell malignancies,where the spectrumof additionalchromosomalalterations is mostly more complex (Martin-Suberoet al., 2007). t(2:14)(p13;q32) leading to IGH-BCLI 1A fusion is another rare but recurrenttranslocationin CLL (Sattenvhite et al., 2001; Kupperset al., 2002). t(14;18)(q32;q21)leadingto IGH-BCL2 recombination and the variants t(18;22)(q21;qlI) and t(2;18)(p12;q21)are secondaryalterationsin a subsetof CLL with trisomy 12 but can also be observedin cases of benign lymphocytosis. t(8;14)(q24;q32) leading to IGH-MYC as well as the correspondinglight-chainvariants targetingMYC can also be observedin CLL, albeit rarely;all these changes seem to be somewhat more common in B-PLL (Merchantet al., 2003; Reddy et al., 2006). Other t(14q32) with rareor privatepartnersare continuouslybeing identified in CLL. Finally, trisomiesfor chromosomes3, 8, and 18 as well as del(6q) and changes leading to gains of 3q26-27, 2p2&25, and 8q24 are among the broad spectrumof changes which have been observed rarely, but recurrently,in CLL (Dohneret al., 1999; Stilgenbaueret al., 1999).

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Clinical Correlations in CLUSLL and B-PLL The prognosticimpact of chromosomal aberrationsin CLL/B-PLLis well established through several extensive studies within or outside clinical trials(Juliussonet al., 1990; Dohneret al., 1995, 1997a. 1997b, 2000; Chevallier et al., 2002; Caballero et al., 2005; Krober et al., 2006; RipollCs et al.. 2006; Greveret al., 2007; Nelson et al., 2007; Stilgenbaueret al., 2007). Consistently, del(17p)lloss of the TP53 locus has been describedas an unfavorableprognostic markerindicatingbad responseor even resistanceto variouskindsof therapy.del( 1 1q) has been shown to be associated with nodal disease and also constitutes an unfavorable marker.The studyby Dohneret al. (2000) showed 17p deletion, 1 lq deletion,trisomy 12, normalkaryotype,and 13q deletionas the sole abnormalityto be associatedwith a median survivalof 32.79, 1 14, I 1 I , and 133 months,respectively.Patientsin the I7p- and I Iqgroupshad more advanceddisease thandid those in the threeother groups. Patientswith 17p deletionshad the shortestmediantreatment-freeinterval,andthose with 13q deletions had the longest. In multivariateanalysis, the presence or absence of a 17p deletion, the presenceor absenceof an I I q deletion,age, Binet stage, the serum lactatedehydrogenase level, and the white cell countgave significantprognosticinformation.These findingshave been confirmed in various independentstudies and clinical trials have been initiated treatingpatientswith del( 17p) and del( I Iq) accordingto high-risk protocols. Moreover, the unfavorablecytogeneticchangeshave been shownto be associatedalso with otherpoor prognosisfeaturessuch as lack of somatichypermutationof the VH region and CD38 and ZAP70 expression (Kroberet al., 2002; Hallek et al., 2008). In the more recent cytogenetic studies using new stimulants,chromosomaltranslocations were found to be associated with 17p abnormalitiesand TP53 mutations,that is, unfavorable prognostic features. Correspondingly,patients with translocationshad a significantlyhigher therapyfailure rate and displayedsignificantlyshortertreatment-free and overall survival as comparedto patients without translocations(Mayr et al., 2006; Haferlachet al., 2007). Multivariateanalyses showed the prognosticimpactof translocations to be independentof established clinical and laboratoryrisk factors. Haferlach et al. (2007) showed the subgroupwith complex aberrantkaryotypesto be significantly associated with an unmutatedVH status and CD38 expression.Thus, all these studies indicate(unbalanced)chromosomaltranslocationsand/orchromosomalcomplexityto be novel and independentprognosticmarkersin CLL. Nevertheless,the results of clinical trials comparing the prognostic relevance of conventional and interphasecytogenetic findings are pending. of CLL is the developmentof a diffuse The most commontype of acutetransformation large cell malignantlymphomaknown as Richter’ssyndrome.No specific chromosome aberrationshaveyet been describedin thisentitythoughtrisomy 12 and del( 1 1 q) seem to be recurrent.In line with other B-cell lymphomasshowing progression,common high-risk aberrationsincludingdel( 17p),t(8q24)/+ 8q24, inactivationof the CDKN2A gene in 9p21, of CLL and chromosomalcomplexityseem to be common findingsduringtransformation (Be&el al., 2002). Mantle Cell Lymphoma Mantlecell lymphomacomprises3-1 0%of all NHL. The incidenceincreaseswith age and there is a strong male predominance(Jaffe et al., 2001). Though its composition of monomorphoussmall- to medium-sizedlymphoidcells resemblingcentrocytesled to the historicalassignmentof MCLto “low-grade”lymphomas,thisdiseaseis characterizedby a

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MATURE 8- AND T-CELL NEOPLASMSAND HODGKIN LYMPHOMA

progressiveclinical course.MCLhas been largelyincurablewith conventionalchemotherapy though modern strategies using immunotherapyand transplantationseem to be promising.Remarkably,nearlyall MCL show some level of leukemic disease, and there is ample evidence that many MCL have in the past been incorrectlyclassifiedas CLL or other low-gradelymphomas.The morphology is variable and a blastic variantof MCL exists, whichmorphologicallymimicsacutelymphoblasticleukemia.Indeed,MCLwas not recognized as a distinct lymphomaentity until the cytogenetic hallmarkof the disease, t(l1;14)(q13;q32), was identified(Banks et al., 1992). The t(11;14)(q13;q32)is present in virtually all cases of MCL independentof their morphologicor clinical presentation(Fu et al., 2005). In approximately20% of the cases, the translocationis part of a more complex rearrangementand loss of the der(l1) is a recurrentphenomenon (Gazzo et al., 2005; Siebert, unpublisheddata). Chromosome numbersare mostly in the diploid or hyperdiploidrangeexcept in blastic variants,which have been associatedwith polyploidy(Ott et al., 1997a). By interphaseFISH, the t( 1 1;14) can be detectedin peripheral bloodor bone marrowat a level of at least I % of the cells in around60%of cases (Bottcheret al., 2008). At the molecular level, the translocationt( I I ;14)(q13;q32) juxtaposes the CCNDl (formerlyBCLI, PRADI) gene next to the ZGH locus leading to overexpressionof cyclin D 1, somethingthatis also detectableby immunohistochemistry. Thebreakpointsin theZGH locus mostly affect the region containingthe J-segmentsand, thus, differfrom the breakpoints of the cytogenetically identical translocationt( 1 1;14) in plasma cell disorders (multiple myeloma, monoclonal gammopathyof undeterminedsignificance (MGUS)), whichclusterto theregioncontainingtheIGHconstantsegments.The breakpointsin 1 1q13 in MCLspreadout overmorethan 150kb, thoughsome clusteringto, forexample,the major translocationcluster (MTC) is seen (Willis and Dyer, 2000; Kuppersand Dalla-Favera, 2001 ; Kuehl and Bergsagel,2002; Dyer, 2003; Kuppers,2005; Jareset al., 2007). Nevertheless, the heterogeneity of the 1 lq13 breakpointsprevents reliable detection of the t( I 1 ;14) by conventionalPCR methods, and FISH is recommendedif the translocation cannot be identified by chromosomebandinganalysis (Martin-Suberoet al., 2003a; van Dongen et al., 2003). Extremely rarevariantsof the t( 1 1;14) are sometimes seen, namely t(2;1 l)(p12;q13) involving ZGK and CCNDI and t(l1;22)(q13;qll)involving IGL and CCNDI, but their diagnostic association with MCL awaits conclusive confirmation (Brito-Babapulle et al., 1987; Komatsuet al., 1993; Wlodarskaet al., 2004). Gene expression profiling studies have recently identified very occasional cases of true t(1 1; 14)-negativeMCL, which instead of activationof CCNDl show expression of the other D-type cyclins, that is, cyclin D2 and D3. Subsequently,the rare but recurrent translocationst(12;14)(pZ3;q32) and t(2;12)(p12;p13)have been describedin t( 11 ;14)negativeMCL, targetingthe CCND2 locus in 12p13 by juxtaposingit next to an IG locus (Gesk et al., 2006; Herens et al., 2008). It is not yet clear whether such cases follow a similar clinical course to that of t( 1 1;14)-positiveMCL. In addition, t(6;14)(p21;q32) and the correspondinglightchain variants( 2 ~ 1 2and 22q 11) involving CCND3 in 6p21 have been identified;however, these translocationsdo not seem to be specific for MCL but ratheroccur in plasma cell disordersand DLBCL (Shaughnessyet al., 2001; Sonoki et al., 2001). Finally, a t(14; 19)(q32;q13)involving CCNEl was identified in a DLBCL (Nagel et al., in preparation).

MATURE B-CELL NEOPLASMS

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Au et al. (2002) revieweddataon 78 MCLfromBritishColumbiaas well as I67 cases of retrieved from the literature.Common aneuploidies included -Y, - 13, -9, -18, +3, and +12. Frequentstructuralrearrangements included 3q, 12q,del(6q), del( 1 p), del( 13q),del( 1 Oq),del( 1 1 q), del(9p), anddel (17p). The most common breakpointclusters were 13321-22, 3~31-32, Iq21, 6qll-15, 6q23-25,8q24,9p21-24,1 lq13-23,13q12-14, and 17~12-13.These findingsarenotonly widely representativeof the patternof secondarychromosomeaberrationsin t( 11; 14)(q13; q32)-positive mantlecell lymphomas,but also show markedresemblanceto the patternof secondarychanges in CLL, not least with regardto the structuralchromosomeaberrations leading to deletions of 13q14, 1 lq22, and 17p. In contrastto what is seen in CLL, the deletions of 13qI4 in some cases affect the RBI gene in MCL (Piny01 et al., 2007). The deletionsof I I q22 and 17ptargettheATM andTP53 genes, respectively,in subsetsof cases (Greineret al., 2006). Complete or partial trisomy 3 leading to gain of 3q27 as well as trisomy I2 are common. Otherrecurrentstructuralaberrationslead to deletions of 1 p22, 8p2 I , 9p2 I , 9q33, and lOp12-I 3 and high-level amplificationsof, for example, the BMII gene in 1 0 ~ 1 2 .t((lq24) with various partnersand gain of 8q24 have been described, particularlyduring disease progression(Ha0 et al., 2002; Michaux et al., 2004). From a series of chromosomal CGH (cCGH) and, more recently, aCGH studies, a consistentpatternof chromosomalimbalancesin MCL has emergedlargely confirmingthe gain/loss patternseen by bandingcytogenetics and underscoringthe nonrandomnatureof the genomic imbalancesthatcharacterizethis disease (de Leeuw et al., 2004; Kohlhammer et al., 2004; Rubio-Moscardoet al., 2005; Tagawa et al., 2005a; Salaverriaet al., 2007). Moreover,partial uniparentaldisomy is common and recurrentlytargetsregions of common chromosomaldeletions in MCL (Nielanderet al., 2006; Bea et al., 2008; Vater et al., 2008). These array-baseddataand the molecularconsequencesof the detectedimbalances have been comprehensivelyreviewed by Nielanderet al. (2007). t( 1 I ;14)-associated lymphoproliferativedisease

+

+

Clinical Correlations in MCL From the clinical point of view, detection of t( 11;14) (q 13;q32) is importantto differentiateMCL from other low-grade B-cell lymphomas,in particularif immunophenotypingis inconclusive.One should keep in mind, however, that also some few cases of true CLL and splenic lymphomawith villous lymphocytes(SLVL) seem to exist with this translocation,cases thatrun a more indolentcourse. The prognostic impact of secondarychromosomalaberrationsin t( 1 I ;14)(q13;q32)-positiveMCL has not yet been rigorouslytested. A recentFISH studysuggestedthatloss of 13q14was associated with a significantlyinferioroutcome (Sanderet al., 2008). cCGH-and aCGH-basedstudies point to losses in 1 7 ~ 1 3and 9q22 as well as gains in 3q as being associated with an unfavorableprognosis (Rubio-Moscardoet al., 2005; Salaverriaet al., 2007). These data were all derivedfroman examinationof retrospectiveseriesof patientswho were not treated accordingto modern strategies,however, and need confirmationin prospectivetrials.

LymphoplasmacyticLymphoma (Waldenstrom Macroglobulinemia) Lymphoplasmacyticlymphoma(Waldenstrommacroglobulinemia;LPL/WM) is characterized by excessive proliferationof an 1gM-producingclone of malignantplasmacytoid cells. The cells typically have both surface and cytoplasmic IgM. They also secrete substantialamountsof IgM resultingin a monoclonal spike on serum proteinelectrophoresis. A variantis gamma heavy-chaindisease (Jaffe et al., 2001).

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MATUREB-AND T-CELLNEOPLASMS AND HODGKINLYMPHOMA

The translocationt(9;/4)(p13;q32)juxtaposingthe PAX5 gene from 9p13 next to the IGH locus has been claimedto be specific for LPL and to be presentin up to 50%of cases (Iida et al., 1996). Recent studies have shown that this frequency is dramaticallyoverestimatedand that t(9;14) can also occur in other types of matureB-lymphoid neoplasms (Ohno et al., 2000; Cook et al., 2004; Poppe et al., 2005; Bar6 et al., 2006). Other translocationsdescribedin matureB-cell neoplasms seem to be rarein LPL/WMthough cases with t( I 1;18)(q21;q2I ) have been described;however, these cases might constitute variantsof marginalzone lymphoma(see below). The most frequentlydetectedchange in LPL/WMis del(6q) and a deletion of 6q21 has been identifiedby FISH in 42% of cases (Schopet al., 2002). As outlinedabove,this 6q- aberrationis ratherunspecific.Otherwise, LPL/WM shows the whole spectrumof aberrationsalready described in CLL, though generallyat lower frequencies.

Hairy Cell Leukemia Hairycell leukemia(HCL)comprisesonly 2%of all lymphoidleukemias.It is a neoplasm of small B-lymphoid cells with oval nuclei and abundantcytoplasmwith “hairy”projections stronglyexpressingCDI03, CD22, and CD1 Ic. It is mainly a disease of middle-aged men; only 20% of the patientsare female (Jaffeet al., 2001). Not only because of the rarityof the disease but also because the hairy cells exhibit low spontaneousmitotic activity and are difficult to stimulate into mitosis, cytogenetic studies in HCL have been few. A normalkaryotype,sometimes with nonclonal aberrations, was found in most cases. Structuralrearrangementsof the long arm of chromosome 14, Udel(l4q),are the changes most frequentlyreportedin this disease (Sambani et al., 2001). t( 14q32) with variouspartnershave been describedas havingalso recurrent interstitialdeletions leading to loss of 14q22-24. It should be cautioned though that these deletions have not been detected by CGH studies. Structuralaberrationsof chromosome 5 seem to be recurrentand two CGH studies identified gains in 5q13-31 in approximately20% of HCL (Nessling et al., 1999; Ostergaardet al., 2001).

Splenic Marginal Zone Lymphoma Splenicmarginalzone lymphoma(SMZL)is a B-cell neoplasmof small lymphocytesthat surroundandreplacethe splenicwhite pulpgerminalcenters,efface the follicle mantle,and merge with a peripheral(marginal)zone of large cells. Lymphomacells may be found in the peripheralblood as villous lymphocytes(SLVL) (Jaffe et al., 200 1). Withoutanalysis of the spleen, differentialdiagnosisfrom otherlow-gradeleukemic B-cell neoplasmsmay be difficult. Up to 40% of SMZL carrya del(7q) (Oscier et al., 1994; Troussardet al., 1998; Ott et al., 2000; Hernandezet al., 200 1 ;Sol6 et al., 200 1 ;Gazzoet al., 2003). The breakpointsof the deletion vary but most losses include the bands 7q3 1-32 (Gruszka-Westwood et al., 2003). A miRNA-29locus in 7q32 has been proposed as a target of the deletion (Mateoet al., 1999; Ruiz-Ballesteroset al., 2007). A second groupof SZML seems to be characterizedby gain of 3q (Sol6 et al., 2001). In addition,a recurrentt(2;7)(p12;q21)has been identifiedin a minorityof SMZLcases activatingthe CDK6gene throughjuxtaposition next to the /GK locus (Corcoranet al., 1999; Brito-Babapulleet al., 2002) (Fig. 10.5). The t(1/;14)(q13;q32)so typical of MCL has been identifiedalso in SMZL. Though it cannot be ruled out that some of these cases may have been mantle cell lymphoma,

MATURE B-CELL NEOPLASMS

2

7

B

317

-*

B

t(2:7)(pl2;q21)

FIGURE 10.5 Translocation t(2;7)(pl2;q21) in splenic marginal zone lymphoma.Fluorescence R-banding.

there seems to exist a true t(l1;14)-positive SMZL in which this translocation is the sole change or at least part of a simple karyotype, contrasting what is seen in MCL (Brito-Babpulleet al., 1992;Troussardet al., 1998). OtherrecurrentIGHtranslocations listed in Table 10.1 have also been observed in rareinstancesof SMZL.The wide rangeof additional chromosome aberrationsthat can be observed in SMZL seems to be rather unspecific.

Extranodal Marginal Zone B-Cell Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT Type) Extranodalmarginal zone B-cell lymphoma of the mucosa-associatedlymphoid tissue comprises 7-8% of all B-cell lymphomasand up to 50% of primarygastric lymphomas (Jaffeet al., 2001). A role of antigenicstimulationby Helicobacter pylori in gastricMALT

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MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

lymphoma,particularlyin the initial phase of the disease, is nowadaystaken for granted (Isaacson and Du, 2004, 2005; Du, 2007). Hrficobacter pyfori eradicationby antibiotic treatmentcan cureat least70%of patientswith gastricMALT lymphomasof limitedstages. A role of infectious agents has also been claimed for MZL at other sites like Borrefia burgdorferi in cutaneousMZL and Chlamydia psitacci in ocularadnexalMALT lymphomas. A special subtypepreviously known as alpha-chaindisease but now called immunoproliferativesmall intestinaldisease (IPSID)occurringin the Middle East and the Cape regionof SouthAfricais associatedwith Campyfobacterjejuniinfection(Jaffeet al., 2001). Chromosomebandinganalyses of extranodalMALT lymphomas,in particulargastrointestinaland pulmonalcases, are today limitedby the fact that these lymphomasare now diagnosed from endoscopicallyobtained small biopsies. Resection of the stomach is no longer the preferredtreatmentin most cases since the introductionof antibiotictherapy whereas most of the banding data derive from the time when gastrectomywas still performed(Horsmanet al., 1992; Ott et al., 1997a). In additionto the banding studies, MALT lymphomashavebeen extensivelycharacterizedby interphasecytogeneticanalyses. There are three recurrenttranslocationsassociated with MALT lymphomasthat are mutually exclusive but all of which target the same cellular complex that links B-cell receptor signaling to activation of NFKB. These translocationsare t( 1 I ;I8)(q21 ;q21), t( 14;18)(q32;q21),and t(1;14)(p22;q32)(Fig. 10.6). The t(/Z;18)(q21;q21)results in an

n

11

n

18 t(11;18)(421;q21)

1

14

t(1;14)(~22;a321

FIGURE 10.6 Recurrent chromosomal aberrationsin marginal zone lymphomas of MALT type and related lymphoid neoplasms. Fluorescence R-banding. (a) Ideogram and partial karyotype with t(ll;lS)(q21;q21) involvingAP12 and MALTI. (b) Ideogram and partial karyotype with t(1;14)(p22; q32) involving BCLlO and IGH. (c) Metaphase with trisomy 3 and trisomy 18.

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APZ2-MALT1 fusion gene (Akagi et al., 1999; Dierlammet al., 1999).This translocationis almost alwaysthe only chromosomalabnormality(Horsmanet al., 1992;Ottet al., 1997b; Barthet al., 2001). When molecularor molecularcytogenetic techniques are used, the t( I 1;18) can be detected in around 15% of all MALT lymphomas.It is seen in MALT lymphomasof all sites but particularlyfrequently in pulmonal (38-53%) and gastric (22-2496) cases (Streubelet al., 2004b; Ye et al., 2005). The t(14;18)(q32;@1) deregulatesthe MALT1 gene throughjuxtaposingit next to the IGH locus (Sanchez-lzquierdoet al., 2003; Streubelet al., 2003). This translocationis cytogeneticallyidenticalto the t( 14;18)(q32;q21)involvingZGH andBCL2 andcan only be discernedby molecular(cytogenetic) means. The t( 14;18) is present in 1 1 % of MALT lymphomasbutprobablymoreoften in ocularadnexal(7-23%)and liver( I 7%) lymphomas than in the others (Streubelet al., 2004b; Ye et al., 2005). The t ( l ;14)(p22:q32)is detectablein less than 2% of MALT lymphomasbut might be more common in pulmonal cases (7-9%) (Streubel et al., 2004b Ye et al., 2005). It juxtaposesthe BCLlO gene next to the IGH locus (Williset al., 1999;Zhanget al., 1999). A variantt( 1;2)(p22;p12)involving the IGK locus has been described(Chuanget al., 2007). Lymphomas with t( 1;14) show a remarkablyconserved patternof additionalchanges comprisingtrisomiesforchromosomes3, 12, and 18 (Williset al., 1999;Zhanget al., 1999; Siebertet al.. unpublished). Trisomy 3 and trisomy 18 can also be observed in translocation-negativeMALT lymphomas (Fig. 10.6). These changes are detected in 30% of all MALT lymphomas, particularlyin intestinal(75%), salivarygland(57%),andorbitaladnexal(35%)lymphomas (On et al., I997a;Streubelet al., 2004b).In addition,chromosomalchangesleadingto partial gainsof 3q (3q27),9q (9q34), and 18q arecommonin MALTlymphomas(Zhouet al., 2006, 2007). Recently,an interstitialdel(6q)targetingthe TNFAZP3 (A20) gene was reportedas a recurrentchange in ocularadnexalMALT lymphomausing aCGH (Honmaet al., 2008). Streubelet al. (2005) identifieda t(3;14)(p14.I;q32)in 10%of MALTlymphomasof the thyroid,ocularadnexa,and skin. Subsequentstudiesshowed thatthis translocation,which juxtaposesthe FOXPI gene from3p 14 next to theIGH locus, as well as otherchromosomal changestargetingFOXPI also occasionallyoccurin otherB-cell neoplasms,includingthe DLBCL (Wlodarskaet a]., 2005; Fenton et al., 2006). There is growing evidence that additional hitherto unknown t( 14q32) involving the ZGH locus exist in lymphomas occumng at MALT sites. A subset of MALT lymphomasacquirea wide variety of changes typically associated with disease progressionsuchas high-levelamplifications,t(8q24)affectingthe MYClocus, del( 17p) leading to loss of TP53, or del(9p) leadingto loss of the CDKN2A locus, and can thentransfoxmintoDLBCL(Barthet al.,200l).Althoughthet(14;18)andt( 1;14)alsooccur in transformedor high-gradelymphomasinvolvingthe MALT, the presenceof t( 1 1;18) is restrictedto low-gradevariants(Barthet al., 2001; Streubelet al., 2004b; Ye et al., 2005).

Clinical Correlations in MALT Lymphoma It has been proven for t( 1 1 ;18) and suggestedfor t( 1 ;14) thatthe presenceof these translocationsindicatesa lower probability of cureby antibiotictherapy.Oncea translocationoccurs,the malignantclone seems to gain a degreeof independencefromthe antigenicstimulusprovidedby, for example,H. pylori (Isaacsonand Du, 2003). Liu et al. (2001,2002) showed that60%of stage IE and 80% of higherstagegastricMALTlymphomasthatdid notrespondto H.pylori eradicationcarrieda t( 1 1 ;18), whereasonly a single respondercarriedthis change. Lymphomaswith t( 1 ;14) mostly presentat advancedclinical stagesand immunohistochemistry for BCLl0 suggests

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that cases carryingthis abnormalityalso do not respondto eradication(Ye et al., 2006). Partialorcompletetrisomy 18 also appearsto predictadverseclinical behavior(Krugmann et al., 2004; Nakamuraet al., 2007).

Nodal Marginal Zone B-Cell Lymphoma (Including Pediatric Marginal Zone Lymphoma) Nodal marginal zone lymphoma is rare and comprises only 1.8% of lymphoid neoplasms. Cytogenetically,nodal marginalzone lymphomahas not yet been well studied. Karyotypesof 75 cases are publicly availablebut the consistencyof diagnoseshas to be questioned(Dierlammet al., 1996; Ott et al., 2000; Aamot et al., 2005b; Callet-Bauchu et al., 2005). t(14;19)(q32;q13)leading to IGH-BCL3 recombinationhas been reported as a recurrentchange (Martin-Suberoet al., 2007). Structural changesaffecting various regions of chromosome 3 also seem to be common as does complete or partialtrisomy 18. The karyotypesare frequentlycomplex and containvariousstructuralrearrangements but as yet no or few specific changes. The aberrationstypical of extranodalmarginal zone lymphomas, like t(11;18) or trisomy 3, do not seem to be frequent in nodal marginalzone lymphoma.

Follicular Lymphoma (Including Pediatric Follicular Lymphoma and Primary Cutaneous Follicle Center Lymphoma) Follicularlymphomacomprises22% of all lymphomasworldwide but shows significant geographicvariation.FL is rarein childrenandthe medianage of incidenceis 59 years.It is a neoplasmresemblingfollicle centerB-cells, thatis, centrocytesand centroblasts.Thereis heterogeneitywith regardto growthpattern(follicular,follicularanddiffuse,andminimally follicular)and the proportionof centroblasts,the latterbeing reflected in three different grades(FL grades 1-3) with grade I showingthe lowest numbersof centroblasts.Grade3 shows the highest number of centroblastsand is subdividedinto grade 3a in which centrocytes are present, and grade 3b with solid sheets of centroblasts (Jaffe et al., 200 I). Variantsinclude diffuse follicle center lymphoma and cutaneousfollicle center lymphoma.Particularly,if consideringthe prominenceof centroblastsin grade3b and variants with diffuse growth patterns, it is not surprisingthat at this end of the morphologicspectrum,FL shows considerableoverlapwith DLBCL (Jaffe et al., 2001). Moreover,thereis a steady rateof approximately3% per annumof transformation of FL mostly to DLBCL(Montotoet al., 2007). Finally,FL and DLBCLmightcoexist in a patient even in the same lymphnode, renderinga cleardistinctionbetweenthe karyotypicfeatures of the two diseases difficult. Approximately80-90% of FL carry a t(14;18)(q32;q21)or very seldom one of its (Johanssonet al., 1995). It is noteworthy variants,t(2;18)(p12;q21)or t(18;22)(q2f;qll) thatthet( 14;18) is extremelyrarein FLpatientsbelow 18 yearsof age andvirtuallyabsentin children below the age of 14 years. A distinct patternof chromosomalaberrationsin pediatric FL has not yet emerged. Ln primary cutaneous follicle center lymphoma, conflicting data on the frequencyof t(14;18) have been published,but if presentat all, the translocation seems to be significantly less common than in nodal FL (Streubel et al., 2006a). InnodalFL, thereis evidencethatthet( 14;18) is morefrequentin FL grades1 and2 (88% accordingto Katzenbergeret al., 2004) than in FL 3, particularlyFL 3b. Ott et al. (2002)

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found t( 14;18) in 8 of 1 1 (73%) FL3a but only in 2 of 16 ( 1 3%) FL3b with or without a DLBCL component.Similarly,Katzenbergeret al. (2004) found t( 14;18) in only 1 of 27 FL3b(4%).Bosga-Bouweret al. (2003) claimedtheexistenceof threedistinctivesubgroups of FL3b based on the presence of breakpointsin 3q27, a translocationt( 14;1S), or the absence of both. None of their FL grade3B cases harboredboth a t( 14;l8) and a 3q27 aberration.Indeed,trisomy3 andbreakpointsin 3q27affectingthe BCM locus arethe most prominentfindingsin t( 14;1@-negativeFL. As thereis convincingevidencefor a biological difference between t( 14;18)-positive and -negative FL, these two groups will in the following be treatedseparately. The nonrandomoccurrenceof t(14;18)(q32;q21) in NHL was first pointed out by Fukuharaet al. (1979). Yunis et al. (1984) mappedthe breakpointsto subbands14q32.3and 18q21.1. The t( 14; 18) has since turnedout to be the most common translocationin NHL ( 15%of the total)butwith considerablegeographicdifferences(Biagi andSeymour,2002). When tested molecularly,the translocationcan also be detected in tissues from healthy donorsto some extent dependingon theirage and externalfactorssuch as smokinghabits and exposureto pesticides (Biagi and Seymour,2002). t( 14;18) is not restrictedto FL but may also be detectedin 30%of DLBCL. In thatlymphoma,the translocationseems to be restrictedto the GCB-typeas definedby gene expressionprofiling(Rosenwaldet al., 2002). The frequenttransformationof FL to DLBCLhas led to the suggestion thatperhapsthose diffuselymphomasthatcarrya t( 14;18)arethe ones thathaveevolved fromfollicularNHL (Knebaet al., 1991). At the molecularlevel, the t( 14;18)(q32;q21) in FLjuxtaposesthe BCL2 oncogenenext to the IGHlocus (Tsujimotoet al., 1984). In molecularterms,the translocationis therefore differentfrom the cytogenetically identical aberrationinvolving MALTZ in MALT lymphomas. In FL, the 18q21 breaks in 60-70% of the cases cluster within a 2.8 kb major breakpointregion (MBR) located in an untranslatedpartof the thirdand last (3’) exon of BCL2;mostof these breaksoccurwithinmuchsmallersubregionsof the MBR (reviewedby Willis and Dyer, 2000; van Dongen et al., 2003). Some 10%of the breakpointsare foundin the moredistalminorclusterregion (MCR). Variantbreakpointshave also been described, including3’ BCL2 (1 2%)and5’ MCR (6%)(Buchonnetet al., 2000,2002). The breakpoints in the IGHlocus fall within the region containingthe J-segments.Indeed,the transiocation is supposed to originatefrom a failed VDJ rearrangement, which in turnarguesthat this lymphomaderives from a precursorcell in the bone marrowratherthan from a germinal centercell. Remarkably,the t( 14;l8)-positiveclone seems to be characterizedby considerable plasticity allowing the tumor cells to become microvascularendothelial cells (Streubel et al., 2004a). The BCL2 gene deregulatedby the translocationencodes an inhibitorof apoptosis (for recent reviews, see Thomadakiand Scorilas, 2006; Zinkel et al., 2006; Letai, 2008). A subset of t( 14;18)-positivelymphomasdo not express intact BCL2 due to somatic mutationsof the gene (Schraderset al., 2005). Vice versa, BCL2 expressionis not restrictedto tumorcells of FLbutcan be observedin a widerangeof B-cell lymphoid neoplasms including,for example, CLL and DLBCL. Less commonvariantsof t(14;18) arethe t(2;18)(p12;q21) and t(18;22)(q21;qZl)that juxtaposetheBCL2gene next to theIGKandIGL loci, respectively.The breakpointsin these variantsare located in the 5‘ end of the BCL2 locus and not in the 3’ end that typically is involved in t( 14;18). Like t( 14;18), both these translocationsalso occasionally occur in CLL, mostly secondarilyto trisomy 12. Indeed,they might evenbe more common in that disease.Due to theirrarity,it is not yet provenwhetherFL with thesevariantsshowthe same clinical course as do t( 14;18)-positiveFL.

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Only in 10% of t( 14;18)-positivecases is this the sole cytogeneticchange (Johansson et al., 1995). Recurrentsecondaryalterationsseen in 10%or more are X, lq21-44, +7, +12q, +18q, del( l)(p36), del(6q), del(lO)(q22-24), and the developmentof polyploidy.The most frequentsecondaryeventarisingafterthe t( 14;18) seems to be duplication of the der(l8)t(14;18)(Johanssonet al., 1995; Horsmanet al., 2001; Hoglundet al., 2004; Aamot et al., 2007). The secondarychromosomalchanges in t( 14;18)-positive FL arise nonrandomlyand in an apparentlydistinct temporal order. Four possible cytogenetic pathwayshave been shown to characterizethe early stages of clonal evolution, which converge on a common route during later stages. Based on these pathways, FL with t(14;1 8) may be classified into cytogenetic subgroupsdeterminedby the presence or absenceof 6q-, +7, or +der( 18)t(14;18).These subgroupsdo not seem to be associated with distinctiveprognosticfeatures,however (Hoglundet al., 2004). The most prominentchanges in t(l4;18)-negative FL are numerical and structural changes of chromosome 3. Horsmanet al. (2003) showed the averagenumberof chromosomal aberrationsto be similarin t(14;I8)-positiveand -negativeFL, namely 7.9 and 8.2, respectively. t(14q32) other than t( 14;18) is present in 28% of t( 14;18)-negative FL. Rearrangements in Ip36 are significantlyless frequentthan in t( 14;18)-positiveFL (8% versus 18%), whereastrisomy 3 is significantlymorefrequent( I 7% versus2%).Trisomy3 may be partof a distinctcytogeneticpatternin t( 14;18)-negativeFL, which also includes trisomy 18. As describedabove, trisomiesfor chromosomes3 and 18 arequitecommonin marginalzone lymphomasand it mustbe questionedwhethersome of the $3, + 18 single or double positive lymphomasare not indeed marginalzone lymphomaswith a follicular growthpatternratherthan true FL. In line with the higherfrequencyof FLgrade3 in t( 14;18)-negativeFL, several studies havedocumentedt(3q27)to be highly recurrentin this disease.Horsmanet al. (2003) found that t(3;14)(q27;q32) was significantly more frequentin lymphomaswithout than with t( 14;18). The overallfrequencyof t(3q27) has been reportedto be below 10%in t( 14;18)positive FL and FL of grades 1 and 2 but to reach 55% in FL3b with a DLBCL(Horsman et al., 2003; Katzenbergeret al., 2004). In contrastto t( 14;18)-positiveFL, t(3q27)-positive FL less frequentlyexpress CDlO and BCL2 (Jardinet al., 2002). The targetof t(3q27) is BCL6, which encodes a transcriptionalregulatorinvolved in germinalcenter formation(Jardinet al., 2007). The BCM (formerlyalso called BCL.5, LAB)gene was identified through cloning of the recurrentt(3:14)(q27;q32)involving IGH and was shown to be involved also in its light-chainvariantst(2;3)(p12;q27)and f(3;22)(q27;qlI)(Kerckaertet al., 1993; Ye et al., 1993a, 1993b; Miki et al., 1994). A steadily growing numberof other t(3q27) translocationsand intrachromosomalchanges in chromosome3 are also being cytogeneticallyidentifiedand molecularlycharacterized, all of which juxtapose BCL6 next to various partners(Table 10.2); for referencingand steady updates, the reader is referred to http://atlasgeneticsoncology.org/Genes/ BCL6ID20.html. Indeed, BCL6 seems to be one of the most promiscuous loci in B-cell lymphomas and translocationsaffecting 3q27 are highly recurrentin various subtypes of B-cell disorders including particularlyDLBCL or nodular lymphocytepredominanceHodgkin lymphoma(discussed subsequently).The common theme of all these translocationsis that the BCL6 promotoris substitutedby the promotorof the partnerthat interruptsits negative autoregulation,a similar effect to that reportedfor somatic BCL6 mutations (Chen et al., 1998; Pasqualucci et al., 2003). Despite this supposed common mechanism of action, considerablemolecular heterogeneityof the breakpointshas been observed. First, an MBR in the 5’ region of the gene is distin-

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guished from the alternativebreakpointregion (ABR) that is located more than 200 kb telomeric (Butler et al., 2002). With regard to the latter, it has not yet been definitely ruled out that also other genes or regulatoryelements than BCL6 may not be involved. Remarkably,BCL6 breakpointsin FL seem to predominantlyaffect the ABR whereas those in DLBCL mostly affect the MBR (Bosga-Bouweret al., 2005). Though the vast majorityof t(3;14)(q27;q32)affects the constantregionsof the ZGH locus, switch gamma translocationsseem to be more prominentin FL (70%) whereasswitch p translocations are more frequent in DLBCL (89%) (Ruminy et al., 2006). A distinctive subtype of t( 14;I 8)-negative FL was recently described. It is characterizedby a predominantly diffuse growth patternand deletions in lp36 (Katzenbergeret al., 2008).

Clinical Correlationsand DiseaseProgression in FL Fromthe findingsdescribed above, a model of FL has emergedsuggesting at least two cytogenetic subtypes: ( I ) FL grades 1 and 2 with t( 14;18) can progressto FL3awhen secondarychangesoccur ortransformto secondaryDLBCLthroughthe acquisitionof tertiaryaberrationsof, for example, 17p (TP53),9p21 (CDKN2A), or 8q24 (MYC) (Christieet al., 2008). Transformationis mostly associatedwith an unfavorableprognosis. (2) FL,mostly of grade3b andlackingt( 14;18) butfrequentlyshowingt(3q27),can also progressto DLBCL throughpathwayssimilarto those of the first group (BosgaBouwer et al., 2005, 2006). A varietyof cytogeneticandmolecularcytogeneticstudieshavecorrelatedchromosomal changesin FL with outcome.Tilly et al. ( I 994) showed thatstructuralalterationsof lp2 1-22, 6q23-26,4q, and I7p were significantlyassociated with reduced5-year survival in FL. In t( 14;18)-positiveFL, del(1 )(p36), del(6q),del(lO)(q22-24), +7, the total numberof abnormalities, the numberof markersand additions,and the presenceof polyploidy have been correlatedwith morphologic progression.In t( 14;18)-positive FL, Hoglund et al. (2004) Iq, 12, 17p-, and 17q- to be correlatedwith an unfavorable reported +X, Ip-, outcomein univariateanalysis,and I2 anddel(17p)also correlatedwith poorsurvivalin a multivariateanalysis that included clinical risk factors.A cCGH study identified loss of 6q25-27 as being associated with unfavorableprognosis(Viardotet al., 2002), and recent aCGH-basedreanalysesconfirmthese findingsand also suggestthatdeletionsof 9p2 I and gain of 1 Iq are unfavorableprognosticmarkers(Schwaenenet al., 2009). All these studies should be viewed with some cautionhowever,since they are all retrospectiveand there is markedheterogeneitywith regardto the treatmentof FL and t(14;I8)-positivity.Studiesof largeseriesof randomizedFLpatientsinprospectivetrialsarestill missingasdo studiestaking of thisdisease(Dave et al., 2004). intoaccountthegene expressionrisk profilescharacteristic

+

+

+

Diffuse Large 6-Cell Lymphoma Diffuse large B-cell lymphomas are a morphologically, biologically, and clinically heterogeneousgroup that constitutes 3040% of all B-cell lymphomas. Based on the site of involvement, some entities such as primaryDLBCL of the CNS and leg-type primarycutaneousDLBCL are distinguishedfrom systemic DLBCL (Jaffeet al., 2001). Hardly any chromosomal data exist on these site-specific diseases but interphase cytogenetic studies have indicated a similar spectrum of changes to that of systemic DLBCL(Hallermannet al., 2004a, 2004b). Some quantitativedifferencesmay nevertheless

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exist, as more than 40% of leg-type DLBCL have been shown by FVSH to have t(8;14) (q24;q32) or variantsand also in the plasmablasticvariant was t(Sq24) often seen by interphasecytogenetics (Hallermannet al., 2004a; Kanungoet al., 2006; Siebert et al., unpublished). Another subtype, ALK-positive DLBCL, in which the tumor cells show a typical immunoblasticmorphology with expressionof VS38 and IgA, was recently recognized based on the expressionof anaplasticlymphomakinase.These lymphomasarecytogenetically characterizedby a simpleor complex t(2;17)(p23;q23)involvingthe clathrin(CLTC) gene in I7q23 and theALK gene in 2p23 (Chikatsuet al., 2003; Gascoyneet al., 2003; Gesk et al., 2005). Cytogenetic data on T-cellhistiocyte-rich large B-cell lymphoma (THRLBCL),an additionalmorphologicsubtypeof DLBCL, are scarce. CGH analysis of 17 THRLBCL showed genomic imbalancesin all cases. The most commonimbalanceswere gain of Xq, 4q13q28, Xp2lpl I , and 18q21 and loss of 17p (Frankeet al., 2002). The nodal andextranodaltypesof DLBCLmostly show centroblasticor immunoblastic morphology (Jaffe et al., 2001). These common DLBCL need to be distinguishedfrom primarymediastinal(thymic)largeB-cell lymphoma(PMBCL)(Jaffeet al.. 2001). Recent gene expressionstudiesshowed the latterto be associatedwith a distinctgene expression signaturerelatedto that of classical Hodgkin lymphoma(Rosenwaldet al., 2003; Savage et al., 2003). Variousexpressionsubgroupsof DLBCLwere also identifiedby these studies. Clinically most relevantwere two subgroupsof DLBCL named accordingto the cell-oforigin signature, that is, “activated B-cell type” (ABC)-DLBCL associated with an unfavorableand “germinalcenter B-cell type” (GCB)-DLBCLassociated with a more favorableoutcome (Alizadehet al., 2000; Rosenwaldet al., 2002). No chromosomalaberrationis completelyspecific forDLBCL,but manyof thegenerally lymphoma-associatedrearrangements are prominentalso in this disease subtype.f(3q27), involving the BCL6 locus and variouspartnersin a mannersimilarto that in FL, is seen in 2 0 4 0 % of DLBCL (Table 10.2). Iqbal et al. (2007) detectedBCM translocationsat the MBR by FISHin 25 (19%) of 133 DLBCLcases, with a higherfEequencyin PMBCL(33%) and ABC-DLBCL(24%) than in GCB-DLBCL(10%). Translocationsof 14q32 involving the IGH locus can be detected in up to half of all DLBCL(Lenzet al., 2007). Approximately20-3096 of DLBCLshow a t(14;18)(q32;q21) (Rosenwaldet al., 2002; Hummelet al., 2006). Thesecases arepredominantlycentroblastic lymphomaand belong almost exclusively to the GCB-DLBCLsubtype(Schlegelberger et al., 1999;Rosenwaldetal., 2002; Iqbaletal., 2004). A t(8;14)(q24;q32)orvariantt(8q24) can be detectedin around10%of DLBCL,some of which mightrepresenttrueBL basedon theirgene expressionprofile(Dave et al., 2006; Hummelet al., 2006). In the others,these translocationsare supposed to be secondary changes mostly associated with a very aggressiveclinical behaviorand in partrelatedto transformationinto lymphomasintermediate between DLBCL and BL (discussedsubsequently).In additionto t(3;14)(q27;q32) and the light-chainvariantst(2;3)(p12;q27)and t(3;22)(q27;qlI ) involvingBCM and the MYC-targetingtranslocationsmore typical of BL, a steadily increasingnumberof other t( 14q32) with heterogeneouspartnersalso exist, particularlyin the ABC-DLBCLsubset (Lenz et al., 2007). Frequentlyrecurringnumericalchromosomeaberrationsin DLBCL include gainsof chromosomesX, 3,7,12, and 18 and losses of the Y chromosomeandchromosomes6, 13, 15, and 17. Based on cytogenetic data, conimonly gained chromosomal regions are 1q23-31, 3q21-22, 6p, 7p, 7q31-32, 8q22-24, 1 lq12-13, 12q14-24, and 18qll-21 in

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centroblasticlymphomasand lq21-25,3p24-q21,6p21,7pl2-21, 18q, and 22q12-qterin immunoblasticlymphomas.Commonlydeletedchromosomalregionsare Ip35-pter,23323pter, 6q21-22, 6q25-qter,8p12-pter,9p21-pter, I lq23-qter, 12~32-13, and 17~12-13in centroblasticlymphomasand 1 p35-36, 2q22-24,4q32-qter, 6q21-25, 7q33, 8q21, 9p24, 9q21-32, I 1q2 1 -qter, I4q23-qter,16p13, and I 8q2I-qter in immunoblasticlymphomas. These imbalances mostly occur as part of complex karyotypeswith many unbalanced translocations.Losses of the whole chromosome 10, deletions in 8q and 14q, as well as structuralabnormalitiesof 4q have been reportedto be significantlymore frequentin immunoblasticthan in centroblasticlymphomas(Johanssonet al., 1995; Schlegelberger et al.. 1999). Recent cCGH and aCGH studies suggest that the main effect of the vast majorityof cytogenetic changes in DLBCL is to create a set of common imbalances that may, at least in part, form the basis for the subgroupsof DLBCL defined by gene expression. ABC-DLBCL frequently show trisomy 3, gains of 3q (including BCL6), 18q21-22 (includingMALT1 and mostly BCL2), and 19q13 (including SPZB), but losses of 9p21 (including CDKN2A) and 6q21-22. GCB-DLBCLshow frequentgains of lq, 2pl3-16 (including REUBCLI IA), chromosome 7, I 1 q, and 12qI2 and PMBCL show gains of 9p21-pter (including JAK2/PDL2) and 2p 14-16 (including REUBCLIIA) (Bea et al., 2005; Tagawa et al., 2005b; Kimm et al., 2007; Wessendorf et al., 2007; Lenz et al., 2008). It has to be stressed that complete or partialtrisomy 9 with a minimal region of gain in 9p23-24 seems to be specific for PMBCL (Bentz et al., 2001). In general, specific chromosomalalterationsmight be associated with significantchanges in gene expression signaturesthat reflect various aspects of lymphomacell biology as well as the host response to the lymphoma (Bea et a]., 2005).

Clinical Correlations in DLBCL All clinical correlations in DLBCL have to be treatedwith extreme caution since the data derive from before the introductionof antiCD20 antibody therapy (rituxan).Moreover, established clinical risk factors and subtyping by gene expression profilingwere mostly not taken into account. The dataon the prognosticimportanceof t( 14;18) and t(3q27) are conflicting;at present,no convincing evidence exists that one or the other is reliably linked to prognosis.Like in many other lymphomas, there is good evidence that del(17p) and de1(9)(p21) in DLBCL are associated with progression and unfavorable prognosis (Tagawa et al., 2005b). In centroblasticDLBCL, deletions and duplicationsof 1q have been reportedto be adverse riskfactorsindependentof the InternationalPrognosticIndex(IPI), whereastrisomy5 and changes of 15q seem to be independentindicatorsof a reduced risk. In immunoblastic lymphomas, changes of 7q and 8q had a strongerimpact on survival than did the IPJ (Schlegelbergeret al., 1999). Recent advances in gene expression profiling and assessment of cytogenetic imbalance patternsoffer new ways to classify lymphomasbased on their cell of origin into prognosticallymeaningful subgroups.The two overlap only to some extent; gains of 3pl1-12 have been shown to provide prognostic informationindependentlyof the gene expressiondata (Bea et al., 2005). It is not likely, however, thatthis way of subgrouping patients exhausts the possibilities for clinically meaningful classification.DLBCL can show considerablemoleculargenetic heterogeneity,includingsomatic hypermutationof IGH, BCL6, MYC, and other genes (Pasqualucci et al., 2001). This and frequent uniparentaldisomy and epigenetic changes are biological parametersalso likely to influence outcome.

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Other Large B-Cell Lymphomas Other very rare entities of large B-cell lymphoma include intravascularlarge B-cell lymphoma (ILBL) and primaryeffusion lymphoma (PEL) (Jaffe et al., 2001). In the formerdisease, hardly any cytogenetic studies have been reportedthough presence of t( 1 1;14)(q13;q32)andt( 14;18)(q32;q21) has beendescribedin singlecases.A recentreview by Mandalet al. (2007) suggestedthat structuralaberrationsof chromosomesI, 6. and 10 and,less frequently,chromosomes4,5, and 8 mightbe nonrandomchangeswith a recurrent site of deletionin 6q21-24. PELis universallyassociatedwith humanherpesvirus8 (HHV8)Kaposi sarcoma herpes virus (KSHV) infection. Also EBV is found in most cases. Cytogenetic analyses mostly show a complex karyotypewith structuralrearrangements frequentlyinvolved in lymphomasin generalhut withoutsubgroup-specificabnormalities (Boulangeret al., 2001). Trisomy7, trisomy12, andaberrationsin the proximallong arm of chromosome1 seem to be recurrent(Wilsonet al., 2002). A CGHstudyidentifiedrecurrent gains of the X chromosomeand 12q (Mullaneyet al., 2000). The majorityof PEL occur in the settingof HIV-infection,which is associatedwith an increased risk of lymphoma. AIDS-related lymphomas include systemic lymphomas, mostly DLBCLand BL, primarycentralnervoussystem lymphomas(PCNSL),PEL, and plasmablasticlymphomaof the oralcavity (Jaffeet al., 2001). AIDS-relatedas well other lymphomasin immunodeficientpatients show a spectrumof chromosomalaberrations similarto that of their counterpartsin immunocompetentpatients(Vaghefi et al., 2006). Activationof MYC and inactivationof TP53 in conjunctionwith EBV (and other viral) infectionseemto play a majorpathogeneticrole (Carbone,2003). Inline with this molecular pathogenesis,there seems to be a trend toward more complex karyotypesand a higher frequencyof t(8;14)(q24;q32)and the varianttranslocationst(2;8) and t(8;22). In lymphomatoidgranulomatosis,which is also an EBV-drivenlymphoproliferative disorderfor which immunodeficientpatientscarryan increasedrisk,no cytogeneticaberrationshaveyet been identifiedthatis in line with an oligo- or polyclonalorigindocumentedparticularlyin low-gradecases (Jaffe et al., 2001).

Burkitt Lymphoma Burkittlymphomais a highly aggressivediseaseoftenpresentingat extranodalsites oras an acute leukemia.Endemic and sporadicBL are recognizedas variantsmanifestingdifferences in clinical presentation and biology. Immunodeficiency-associatedBL is seen primarilyin associationwith HTV. The hallmarkof Burkittlymphomais the t(8;Z#)(q24;q32)and its variants,t(2;8)(pZ2; 924) and t(8;22)(q24;qll).These translocationsarepresentin both the endemic,African tumor type and in the sporadic BL occurringin Europe, America, and Japan, both in Epstein-Barr virus (EBV)-infected and in EBV-negative BL. The t(8;14) is present in 75-85% of all BL (Johanssonet al., 1995). In 15-25%, one of the varianttranslocations is found with the t(8;22) occurringtwice as frequentlyas t(2;8) (Fig. 10.7). BL was the firstlymphoidneoplasmsin which the underlyingchromosomalrearrangement was characterized.The firstcytogeneticstudyof BL was reportedin I963 by Jacobs andcoworkers.Aftertheintroductionof bandingtechniques,ManolovandManolova(1972) describedan additionalbandat the end of 14q in five of six fresh BL and in seven of nine cell lines fromsuchtumors.The natureof theBL-specificabnormalitywasclarifiedby Zech et al. (1976), who established that the 14q- arose through the translocationt(8;14)

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FIGURE 10.7 Burkitt translocation t(8; 14) and variants. (a) Ideogram and partial karyotype with t(8; 14)(q24;q32) involving MYC and IGH. (b) Ideogram and partial karyotype with t(2;8)(p 12;q24) involving IGKand MYC. (c) Ideogramand partial karyotypewith t(8;22)(q24;q1 I ) involving MYCand IGL. Fluorescence R-banding.

(q24:q32). Based on a high-resolutionstudy, Manolova et al. (1979) reportedthat the translocationwas reciprocal.Furtherscrutinyof prophase-prometaphasecells from the BL-derivedcell line DaudiallowedZhanget al. (1982) to mapthe translocationbreakpoints to subbands8q24.I3 and 14q32.33. Berger et al. (1979) describedthe first varianttranslocation, t(8;22)(q24;qlI ) , and Miyoshi et al. (1979) and van den Berghe et al. (1979) simultaneouslyreportedthe second variant,t(2;8)(p12;q24). The molecularconsequenceof the t(8;14) and its variantsis deregulationof the MYC oncogenein 8q24 throughjuxtapositionnext to one of the IG enhancerelementsin the IGH (14q32),iGK (2pI2), or E L(22q I 1 ) locus. Activationof MYCtakesplace on the der(14) in t(8;14)andon the der(8)in t(2;8)andt(8;22).Correspondingly, the breakpointson the der(8) differbetweenthe t(8;14) and its variantsbeing telomericof the MYCgene in the latterand centromericof MYC in the former.Breakpointscan scatterover severalhundredkilobases on both sides of the MYC locus (Jooset al., 1992a, 1992b;Einersonet al., 2006). Sporadic, BL show differentclusteringof thebreakpoints endemic,andimmunodeficiency-associated on der(14) andder(8)indicatingthatdifferentpathogeneticmechanismsmay be behindthe generationof thet(8;14) in thesedifferentdiseasesettings.Briefly,thebreakpointsof t(8;14) in endemic BL frequentlyfall far centromericof the MYC gene and regularlyaffect the J-segmentsof the IGH locus. In contrast,t(8;14) in sporadicBL more frequentlyinvolves the switchregionsof theconstantsegmentsof IGHorthe breakpointoccursbetweenexons 1 and2 or immediately5’ of theMYCgene. This molecularheterogeneityhas to be takeninto accountwhen diagnosingone of the translocationsby molecularor molecularcytogenetic

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MATURE6-AND T-CELLNEOPLASMS AND HODGKINLYMPHOMA

techniques.In addition,somaticmutationof the MYC locus occursfrequentlyin BL, which mightin partbe drivenby theVH mutationmachineryafterthejuxtapositionof MYCnextto IGH. Some of the mutationsin MYC, which may also occur independentlyof IGH-driven hypermutation,might be of pathogeneticrelevance. For more details on the molecular characteristicsof the Burkitttranslocationsas well as the pathogenicconsequencesof MYC activationin general, the readeris referredto excellent reviews by, for example, Willis and Dyer (2000), Boxer and Dang (2001), Kuppers and Dalla-Favera (2001), and Kuppers(2005). A characteristicfeatureof BL is thatthe t(8;14) or varianttranslocationtypicallyis part of a rathersimple karyotype;complex karyotypes in BL indicate disease progression (Johanssonet al., 1995;Hummelet al., 2006; Boermaet al., 2008; Salaverriaet al., 2008b). Secondarychromosomalchanges are present in around 60% of BL. The clearly most frequent secondary aberration(>30% of all patients) is structurul rearrangement of chromosome I , in particularof the long arm and often leading to partialtrisomy for lq. Trisomy 7 and trisomy 12 are othercommon secondarychanges.These three aberrations tendto be mutuallyexclusive in BL progression(Boermaet al., 2008). Anotherhot spot for secondaryinvolvement in BL is chromosomal region 13q3, found rearrangedin 15% (Johanssonet al., 1995). The targetis most likely the miR-17-92 m i W A locus that,like other recurrentmolecular changes, seems to interactwith MYC in transformation(He et al., 2005; O’Donnell et al., 2005). Accordingto the 2001 WHOclassification,all cases of BL haveto carrya t(8;14), t(2;8), or t(8;22), or its molecularcounterpart(Jaffeel al., 2001). Thus,by definition,BL without one of these translocationsdoes not (anymore)exist, and some of the cases reportedin the literaturelacking cytogenetic or molecularevidence of the specific BL-translocation(s) would nowadaysnot have been diagnosedas BL. The view that BL is a homogenousdisease characterizedby the presenceof one of the three specific translocationsis also supportedby recent gene expressionprofilingstudies (Dave et al., 2006; Hummelet al., 2006). Nevertheless,none of the threetranslocationsis completely specific for BL as all of them have been described in almost all B-cell lymphomas.Remarkably,“B-cell lymphomawith featuresintermediatebetween DLBCL and BL” is a disease subset stronglyenrichedfor the presenceof these translocationsand might even present with a typical Burkittleukemiamorphology in the bone marrow.In contrastto BL, these intermediatelymphomas,which occur at a significantlyolder age, mostly show complexkaryotypes(Hummelet al., 2006;Boermaet al., 2008). Manyof them harborother recurrentIG-translocations,like t( 14;18)(q21 ;q32) or t(3q27) targetingthe BCL6locus, the so-called “doublehits”(Daveet al., 2006; Hummelet al., 2006). Moreover, a wide rangeof t(8q24) not involvingIG loci as partners,like t(8;9)(q24;pl3)juxtaposing MYC to the region containing PAX5 and t(3;8)(q27;q24)juxtaposing MYC to BCM (Hummel et al., 2006; Bertrandet al., 2007; Sonoki et al., 2007), may also occur. The detectionof a doublehit,the presenceof a non-IG-MYCtranslocation,andthe occurrenceof a t(8;14) or variantas part of a complex karyotypeshould, particularlyin nonpediatric patients,lead to a reassessmentof the histopathologicdiagnosis,especially since each of these three featuresis associated with an unfavorableoutcome (Hummel et al., 2006).

Plasma Cell Neoplasms The group of plasma cell neoplasms (PCN) includes solitary plasmacytomaof bone, extraosseousplasmacytoma,and plasmacell myeloma (or multiple myloma), the latter

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including the clinical variantsnonsecretorymyeloma, smoldering myeloma, indolent myeloma, and plasma cell leukemia (PCL). Monoclonal gammopathyof undetermined significance is regardedas a precursorstate and approximately25% of patients with MGUS develop an overt lymphatic, mostly plasma cell, neoplasm after a follow-up of morethan20 years.Also variouskindsof monoclonalimmunoglobulin(heavy-and lightchain) deposition diseases related to amyloidosis are included among the plasma cell neoplasms (Jaffe et al., 2001). From the cytogenetic point of view, these plasma cell disorders,as far as they have been characterized,are closely related showing a similar spectrum of changes (Fonseca et al., 2002; Harrisonet al., 2002; Chng et al., 2005; Brousseauet al., 2007). Since the introductionof cytogeneticanalysesinto the studyof plasmacell neoplasias,it has been repeatedlyshownthatmultiplemyelomais a heterogeneousdiseasewith regardto the underlyingchromosomalabnormalities(Dewald et al., 1985; Calasanzet al., I997a; Nilsson et al., 2003). Karyotypingof multiplemyeloma has been hamperednot only by a low level of bone marrowinfiltrationanda low mitoticindexof plasmacells in vitro,but also by the fact that many of the translocationsaffectingthe IGH locus in 14q32 are cytogenetically cryptic in this disease. The 30% of cases showing aberrationsby this analysis thereforegrossly underestimatesthe actual level of karyotypicchanges in MM (Dewald et al., 1985;Calasanzet al., 1997a;Nilsson et al., 2003). In addition,poormetaphasequality in many MM cases has preventedthe identificationof recurrentaberrations,including translocations,by chromosomebanding.In those cases that have shown abnormalkaryotypes, numerousstructuraland numericalabnormalitieshave often been found, and some patientshave had multipleabnormalclones. Nevertheless,around25% of the karyotypes have shownonly one or two abnormalities(Calasanzet al., 1997a;Nilsson et al., 2003). The frequencyand extent of karyotypicabnormalitiesseem to correlatewith the disease stage. Therefore,most chromosomalchanges describedby conventionalcytogeneticsare more likely to be encounteredin a highly proliferativeclone and arenot clearlyassociatedwith early disease stages (Hallek et al., 1998). Two large and independentbioinformaticanalyses of the clusteringof chromosomal changes have shown that at least three cytogenetic subgroupsof plasma cell neoplasias exist (Debes-Marunet al., 2003; She, et al., 2004): (I) A hyperdiploidgroupaccountsfor 30-50% of the cases and is characterizedby gains (mostly trisomy or tetrasomy) of chromosomesand chromosomearms9/9q, 19,5, and 15/15q, as well as 3, Ill1 Iq, 7, and 21. These neoplasms show only a low frequency of t(14q32) (9%), -14 (8%), and VdeI(22q)(7%). Monosomy 13 is seen in 20% of these cases. (2) A hypodiploidgroup accounts for 20-35% of the cases and shows monosomy 13 in around two-thirds. t(14q32) (25%). -14 (42%), and t/de1(22q) (34%) are significantlymore frequenthere thanin the hyperdiploidgroup.(3) A thirdpseudodiploidgroupaccountingfor 20-35% of the cases contains t( 14q32) in up to 75%. Monosomy 13 is seen in one-fourthof these cases. There seems to be some overlapbetween the lattertwo groups,which also show other recurrentaberrationslike gainsof 9q, 12q, 17q, 18,and22q, losses of X, 6q, 8,16, andY, and structuralaberrationsinvolving 16p or 16q, l p or lq (partialdeletion,trisomy lq). 1 Iq 13, 19q13 or 1 9 ~ 1 36q, , 17q, and 7q (Dewald et al., 1985; Calasanzet al., 1997a; Nilsson et al., 2003). By means of CGH, Avet-Loiseauet al. (1997) foundthat losses from 13q and 14q and gains from 1q and 7 occurredin 50-60% of MM patients,with hot spots at 13q12.1-2 1, 13q32-34, 14q1 1.2-13, and 14q23-3 I . Cigudosa et al. ( 1998) suggested that the most

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frequentevents were gains of chromosome19 or 1% and complete or partialdeletionsof chromosomeI 3. Also gainsof 9q, I 1q, I2q, 15q, 17q,and22q andlosses of 6q and 16qhave been describedin MM based on CGH studies (GutiCrrezet al., 2004). Using multicolorspectralkaryotyping(SKY), severalrecurringsites of breakagewere mappedto chromosomalbands3q27,17q24-25, and20q 1 I by Rao et al. (1998). Also new translocationsinvolving 14q32 were identifiedusing this approach,namely t( 12;14)(q24; q32), t( 14;2O)(q32;qlI), t(14;16)(q32;q23),andt(9;14)(p13;q32)(Raoet al., 1998;Sawyer et al., 1998,200 1 ). Studies using interphaseFISH have demonstratedthat numericalchromosomeabnormalities are present in up to 90% of multiple myelomas (Drach et al., 1995; Flactif et al., 1995;Zandeckiet al., 1996).Amongthem,partialorcompleteloss of chromosome13 is the mostcommon(Shaughnessyet al., 2000;Fonsecaet al., 2004). It is worthyof notethat in contrastto CLL,thedeletionsmostly affectthe whole 13qarm.Althoughthe monoallelic deletion of RBI through monosomy 13 or 13q deletions is a frequent event in MM (Shaughnessyet al., 2000), mutationsor rearrangementsof RB1 have not been described, and biallelic loss of the RBI gene is infrequent(Juge-Morineauet al., 1995; Zandecki et al., 1995). Deletions of 1 7 ~ 1 3occur in up to 10%of MM, as detected by interphaseFISH (Drach et al., 1998; Fonseca et al., 2003; Chang et al., 2005a, 2005b). Mutationsof TP53 are infrequentlyfound in newly diagnosedMM, but occurmoreoften in relapseor in patients with PCL (Neri et al., 1993). Translocationsof 14q32involvingIGH are seen in 5 0 4 0 % of patientswith plasmacell neoplasia(Bergsagel and Kuehl, 2001; Avet-Loiseauet al., 2002; Higgins and Fonseca, 2005). The IGH translocationsare mediatedmainly by errorsin immunoglobulinclass switch recombination(Bergsageland Kuehl,2001) and have been suggestedto be early,if not initiating,pathogenicevents (Bergsagelet al., 2005). In additionto t( 14q32) involving the IGH locus, varianttranslocationsof 2p12 and 22q 1 1 have been described in MM involvingeitherthe 1GK or the IGL light-chainlocus.The limitedstudiesavailableindicate that the prevalenceof IGL translocationsis around20% in advancedintramedullaryMM tumorswhereas1GK translocationsare quite rare,occurringin only a small percentageof intramedullary MM (Bergsageland Kuehl,2001). Two separateand independenttranslocations involving IGH and/or IG light-chainloci seem to infrequentlyoccur only in MM tumors,but may be presentin 5- 10%of advancedtumorsandprimaryPCL(Bergsageland Kuehl, 2001). UnlikeotherB-cellmalignancies,MMexhibitsawidevarietyofdifferentlGtranslocations involving numerouspartnerchromosomes.Some of these IG translocationsare recurrent, whereasothersarerareorunique(Table10.5).Theclinicalrelevanceof manyof themremains to be determined(Bergsageland Kuehl, 2001). Morethan40%of MMhaveIGtranslocations involving seven recurrentchromosomal partners and oncogenes (Table 10.4): 1lql3 (CCNDI),4p16 (FGFR3 and MMSET), 6p21 (CCND3),16q23 (MAF), 2Oq11 (MAFB), 6p25 (IRF4), and lq21 (IRTAMRTAZ). t(Zf;f4)(q13;q32)is the most common (1520%) translocationfound in MM (Lai' et al., 1995; Avet-Loiseau et al., 1998; Gertz et al., 2005). The breakpointsin 1 lq13 are scatteredthroughoutthe 360 kb region between the CCNDI gene and the MYEOV gene (myeloma overexpressedgene) (Ronchetti et al., 1999; Janssen et al., 2000). In 14q32, the breakpointsfall either within the JH or, in contrastto MCL, in the switch region (Bergsagel et al., 1996). Similar to MCL, the translocationleads to deregulated expression of CCNDI;however, due to the presence of IGH enhancer(s)on der(11) in

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TABLE 10.5 Recurrent IG Translocations in Multiple Myeloma (Updated from Kuehl and Bergsagel, 2002) ChromosomalBand

Oncogene Product

Incidence

I lq13 6p2 1 4p16 I6q23 6p25 20ql I 8q24 Iq2l

CCNDI CCND3

15-20% 5% I &20% 5-10% 5% 2-5%

FGFR3 and MMSET MAF

lRF4 MAFB MYC IRTAMIRTAZ

I% 1-2970

Rare variants include, among others, 2p23 (MYCN), 9p13 (supposedly PAX5), 1 lq23 (supposedly M U ) , 1 2 ~ 1 3(supposedly CCND2). and 17q21 (NIk').

M M , MYEOV gene expression may also be deregulated.Besides the classical balanced translocationt( 1 I ;14)(q13;q32),morecomplex rearrangements, too, includinginsertions, have been reportedaffecting 14q32 (IGH) and I lq13 (CCNDI) (Gabreaet al., 1999; Fenton et a]., 2004). The cytogenetically cryptic t(4;14)(p16.3;q32.3) is found in 1 6 2 0 % of MM when appropriate FISHtechniquesareused (Avet-Loiseauet al., 1998;Fonsecaetal., 2003; Gertz et al., 2005). In the IGHlocus, all the breakpointsoccur in switch regions (Bergsagel and Kuehl, 200 1). In 4p 16, the breakpointsoccur 50- I00 kb centromericof the FGFR3 gene, clusteringwithin a region of about 60 kb within the 5' exons of the MMSET gene (Chesi et al., 1998a).TheMMSETgeneon the der(4)becomes deregulatedbecauseof the presence of the IGH intronicenhancer.In addition,hybrid mRNA transcriptsare formed between IGH (JH and 1p exons) andthe MMSETgene(Chesiet al.. 1998a;Keatset al., 2005). On der ( 1 4), FGFR3 is juxtaposedto the strongIGH 3' enhancers,and its expressionis consequently deregulated(Chesi et al., 1998a). The FGFR3 gene has been reportedto be expressed in only 70-75% of t(4;14)-positivecases, and the lack of FGFR3 expression normallycorrelateswith loss of the der(14)t(4;14)chromosome(Keatset al., 2003; Santra el al., 2003). MMSET,on the otherhand,is deregulatedby the Ep enhanceron the der(4)in all t(4;14)-positiveMM (Chesi et al., 1998a; Santraet al., 2003). A t(14;16)(q32;q23)has been identifiedin 5-1 0%of patientsand in about25% of MM cell lines (Chesi et al., 1998b; Avet-Loiseau et al., 2002; Fonseca et al., 2003). This translocationis difficultto detect by conventionalkaryotypingbut has been reportedin 7% of MM patients with abnormalmetaphasesstudied by SKY (Sawyer et a]., 1998). The breakpointsin the IGH locus mostly occurin switch regionsoroccasionallyin theJHregion (Chesiet al., 1998b;BergsagelandKuehl,2001). The breakpointsin I6q23 occurin a region 550-1350kb centromericto MAF, within the 800 kb intron of the oxidoreductasegene WWOWFOR(Bednareket al., 2000; Ried et al., 2000). As aresultof the translocation,MAF, the cellularhomologueof v-rnaf,which is the transforming gene of the avianmaf retrovirus, is juxtaposedto the IGH enhancersandhighly upregulated(Chesiet al., 1998b).On der(16), the translocationinactivatesone allele of the WWOWFOR gene (Bednareket at., 2000). However,the identificationof a cell line carryinga t(16;22)(q23;qlI )varianttranslocation affectingIGL (22qll) (Chesi et at., 1998b)and with breakpointstelomeric of MAF (not involving WWOWFOR), suggests that inactivationof one allele of WWOWFOR by the t( 14;16) translocationis not requiredfor MM cell transformation.

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The t(Z4;20)(q32;q12)was firstidentifiedby spectralkavotyping(Raoet al., 1998)andis presentin 2-5% of MM (Hanamuraet al., 2001 ;Kuehl and Bergsagel,2002; Barill6-Nion et al., 2003). The breakpointson der(20) occur 0.5-1 Mb centromericof the MAFB gene, scatteredwithinan800 kbregion(Hanamuraetal.,200 1 ;Boersma-Vreugdenhil et al.,2004). The deregulationof CCND3 as a resultof t(6;14)(p21;q32) is detectablein 5% of MM (Shaughnessyet al., 2001 ;Sonokiet al., 200 1). All cloned breakpointsin 14q32occurredin the IG switch regions, whereasthe breakpointsin 6p21 clusteredto a region no morethan 150 kb 5’ (centromeric)to the CCND3 gene. A varianttranslocation,t(6;22)(p21;q//), involving IGL and CCND3has also been describedin MM in which the breakpointswere telomericto the CCND3 gene (Shaughnessyet al., 2001). A steadily growing numberof other and less common IGH translocationshave also been describedin MM (Table 10.4), includingt(6;14)(p25;q32) involving the IRF4 gene (Yoshida et al., 1999; Kuehl and Bergsagel, 2002) and t(1;14)(q21;q32) involving the IRTAIIIRTAZ locus (Hatzivassiliouet al., 2001). Among the IG translocationsin MM arealso the t(8;14)fq24;q32)andits variantstargetingtheMYCgene(Bergsagelet al., 1997; Avet-Loiseau et al., 2001). They give rise to 10-15% of the MYC aberrationsin MM (Shou et al., 2000; Avet-Loiseauet al.. 2001; Gabreaet al., 2008). In total,the frequencyof abnormalitiesaffectingthe MYClocus in primarytumorsrangesfrom approximately15% (Avet-Loiseau et al., 2001; Fabris et al., 2003) to 45% (Shou el al., 2000). These abnormalitiesinvolving MYC appearlate in the course of MM and are consideredto be associatedwith tumorprogression(Shou et al., 2000; Bergsagel and Kuehl, 2001). It is worthy of note that the 8q24 aberrationsare highly heterogeneousin termsof breakpoint positions (Fabriset al., 2003). The expression level of CCNDI, CCND2, or CCND3 mRNA in MGUS and MM is consistentlyhigherthan in normalplasmacells (Tarteet al., 2002; Zhanet al., 2002), and almost all MGUS and MM tumorsderegulatea1 least one of the cyclin D genes (Bergsagel et al., 2005). Therefore,the ubiquitousderegulationof cyclin D genes in MGUS andMM, sometimes as a consequence of iG translocationsbut otherwise by presentlyunknown mechanisms, appears to be a unifying and early, if not initiating, pathogenic event (Bergsagel and Kuehl, 2005; Bergsagel et al., 2005). It has been proposed that the type of cyclin D expressed,togetherwith the patternof chromosomalchangesobserved,might be used to classify MM into biologically and clinically relevantsubgroups.

Clinical Relevance of Chromosomal Aberrations in Plasma Cell Neoplasias Two decades ago, Dewald et al. (2985) provided evidence that patients with newly diagnosed MM and abnormalmetaphasesby chromosome banding had active disease and reduced survival compared to patients who had only normal metaphases. This conclusion was later corroboratedin several studies. Tricot et al. (1995) found that patients with MM who had metaphase cells with monosomy 13 and/or structural anomalies of chromosome I3 detected by conventionalcytogenetics, had even shorter survival.Calasanzet al. ( 1997b) reportedthat among other chromosomalabnormalities, hypodiploidy and rearrangementsof chromosome band 22qll signified a higher progression rate and shortersurvival in MM patients. Independentstudies confirmed the importanceof these chromosomalaberrationsand also pointed towardother aberrations as powerfulprognosticmarkersin MM (Pirez-Sim6n et al., 1998; Rajkumaret al., 1999; Smadjaet al., 200 I ;Fassaset al., 2002). Among them, translocationsaffectingIGHsuch as the t(4;14) and the t( 14;16) and deletions of TP53 in 17p13 were repeatedlyreported to confer a negative outcome in MM (Fonseca et al., 2003; Keats et al., 2003; Chang

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et al., 2005a, 2005b; Gertz et al., 2005). t(4;14) and t(14;16) were shown to correlate with a poor prognosis not only in untreatedpatients (Dewald et al., 2005) but also in patients treated with high-dose or conventional chemotherapy(Fonseca et al., 2003; Gertz et al., 2005; Avet-Loiseau et al., 2007; Gutitrrez et al., 2007). The t(l1;14) translocation,present in up to 15% of MM, was first associated with an aggressive clinical course (Fonseca et al., I999), but more recent studies suggest that these patients do not fare as badly as initially thought(Fonsecaet al., 2003; Dewald et al., 2005; Gertz et al., 2005). Several reports have described the importanceof deletions of the TP53 locus for estimatingoverall survival and time to progression(Changet al., 2005a), but other studies have failed to demonstratean independentprognostic value of TP53 deletions in multivariateanalyses (Gertz et al., 2005). Theresultsof studiesof the clinical impactof chromosome13 changesarenot clear-cut. Some have claimed that patientswith chromosome 13 anomalies in their metaphaseor interphasecells have a poor prognosis (Tricot et al, 1995; Avet-Louseauet al., 2000; Kaufmannet al., 2003; Krogeret al., 2004), but othershave indicatedthat chromosome 1 3 anomaliesmaynotbe as importantforsurvivalastheobservationof t(4;14),t( 14;16),ordel (17)(p13) (Fonseca et al., 2003; Chang et al., 2005a, 2005b; Gertz et al., 2005; Chng et al., 2006). Other reportsagain indicate a strong association between the presence of chromosome13 anomaliesand t(4;14), t(14;16), or de1(17)(p13.1)(Fonseca et al., 2001; Magrangeaset al., 2005), andone can only concludethatat presenttherelationshipbetween chromosomeI3 anomaliesand prognosisis unclear.Some recentresults suggest that the prognosticsignificanceof chromosome13 anomaliesdependson whethertheyweredetected inmetaphaseorinterphasecells (Dewaldet al., 2005). In thatstudy,detectionof chromosome 13 anomaliesin metaphasecells was associatedwith poorprognosis,whereaspatientswith chromosomeI 3 anomaliesdetectedin theirinterphasenuclei had intermediatesurvival. In the recentpast, several independentstudieshave establisheda hierarchyof chromosome anomaliesin MM thatcorrelatewith patientprognosis(Fonsecaet al., 2003; Chang et al., 2005a, 2005b; Dewald et al, 2005; Avet-Loiseauet al., 2007). Fonsecaet al. (2003), using interphaseFISH for the detection of specific anomalies, found that patients with t(4;14), t(14;16), and/orde1(17)(p13.1)had a poor prognosis,those with chromosome13 anomalieswithoutt(4;14), t( 14;16),and/ordel( 17)(p13.1)had intermediateprognosis,and those with other chromosome anomalies, including most patients with t( 1 I; 14), had a favorable prognosis. Similar conclusions were drawn by Chang et al. (2005a, 2005b). Dewaldet al. (2005) reachedsimilarresultsbutwith a differenthierarchyformetaphaseand interphasedata.For metaphasedata,patientswith t(4;14), t( 14,16), del(l7)(pl3.l), and/or chromosome13 anomalies had poorersurvivalthan did patientswith t( I 1;14) and other anomalies.Forinterphasedata,patientswith t(4;14)ort( 14;16) had poorersurvivalthandid patientswith chromosome 13 anomalies,del( I7)(pl3.1), t( 1 I ;I4), and otheranomaliesor who had no anomalies. Limited data are available on the impact of other recurrentgenetic aberrationson prognosisin MM. The prognosticsignificanceof chromosome11 aberrationsis controversial. They have been associatedwith a poorprognosisin severalstudies(Tricotet al.. 1995; Gutierrezet al., 2004). However,Cremeret al. (2005) recently showed that the response status after autologous stem cell transplantationin patients with 1 I q aberrationsversus those without did not indicate an adverse prognostic significance. Finally, structural aberrationsof chromosome1 have also been associatedwith an adverseprognosticimpact and a poor clinical outcome in MM (Debes-Marunet al., 2003; Segeren et al., 2003; Hanamuraet al., 2006; Wu et al., 2007; Hillengass et a]., 2008).

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Withregardto thedetectionof prognosticallyrelevantchromosomalalterations,FISHon immunologicallyselected plasma cells (e.g., FISH of plasma cells enrichedby MACS, Immuno-FISH,FICTION)is nowadays recommended.Probes for the detection of the translocationst( 1 1 ;14),t(4;14),andt( 14;16) areapplied,possibly togetherwith a probethat detectssplittingof IGHin general.FISH testing shouldalso be aimedat detectinglosses of 13q and 17p as well as gains of lq. The hyperdiploidvariantof MM associatedwith a favorableoutcomecan be identifiedby probestargetingtrisomiesforchromosomes5,9,15, and/or 19. Despite all recentprogressesin prognosticationby interphaseFISH and other techniques,chromosomebandinganalysiscan add independentprognosticinformationon plasmacell disorders,as demonstratedby Dewald et al. (1985,2005), and is thereforestill highly recommended.

MATURE T-CELL AND NK-CELL NEOPLASMS A comparativeoverview of the differentsubtypesof matureT-cell neoplasmstakinginto account the Kiel, REAL, and 2001 WHO classificationsis provided in Table 10.6. The clinically most relevantchromosomalaberrationsare summarizedin Table 10.7.

T-cell Prolymphocytic Leukemia T-cell prolymphocyticleukemia is a rare lymphoproliferativedisease with distinctive morphologicappearance,a mostly maturepost-thymicimmunophenotype,and an aggressive clinical course. It comprisescases previouslyclassifiedas T-cell chroniclymphocytic leukemia(T-CLL)(Jaffe et al., 2001). The genetic hallmarkof T-PLLis inv(f4)(qllq32), firstassociatedwith T-CLLby Zech et al. (1983), which is present in up to 80%of the cases. Its variant,t(14;14)(qll;q32), is detected in 10%of T-PLL. Both chromosomalaberrationsjuxtapose the TCLf locus in 14q32 next to the TCRAD locus in 14qlI resulting in upregulationof the TCLlA gene (Virgilioet al., 1994).The translocationt(X;14)(q28;qll)is thecharacteristicchange in T-PLL lacking inv(I4) or t(14;14). It juxtaposes the MTCPl (for mature T-cell proliferation-1)gene from Xq28 next to the TCRAD locus in 14ql I (Stem et al., 1993). The centralimportanceof T-cell receptorrearrangementsin the pathogenesisof T-PLLis furtherunderscoredby the fact thatdeletionsand translocationsof 7q34-36, the site of the TCRB gene locus, are also found repeatedly(15%). Besides the describedTCR-associatedtranslocationsthat are regardedas the primary oncogenic events in T-PLL, the tumorcells usually harboralso a high load of additional changes.The patternof these secondaryaberrationsis highly characteristicfor T-PLLand seemsto be associatedwithchangesin thegene expressionpatternof the tumorcells(Soulier et al., 200 I :Duriget al., 2007). In up to 80%of cases, overrepresentations of 8qanddeletions of 8p, Frequentlydue to formationof an isochromosome,i(8q), arepresent.The breakpoint of the i(8q) is in 8p spreadover a large genomic region arguingagainst a breakpointassociated oncogenic mechanism but for a gene dosage effect caused by the resulting imbalances,which is in linewith the findingsof recentgene expressionstudies.Alterations of chromosome 6 leading to gain of or from 6p but losses from 6q as well as structural changes of 22q have also been observed in a significantproportionof patients. Other recurrentchangesare deletionsin I Opand 18p.Finally,del(l1q) leads to loss of one copy of the ATM gene while mutationsarecommonin the second allele (Stilgenbaueret al., 1997).

MATURET-CELLAND NK-CELLNEOPLASMS

335

TABLE 10.6 Comparison of the Kiel, REAL, and WHO Classifications of T- and NK-Cell Malignant Neoplasms (Lennert, 1975; Harris et at., 1994; Jaffe et al., 2001)" Kiel Classification

T-lymphocytic, CLL type T-lymphocytic, PLL T-lymphocytic, CLL type

REAL Classification

WHO Classification 200 I

PeripheralT-cell and NK-Cell Neoplasms

Mature(Peripheral)T-cell and NK-Cell Neoplasms

T-CLLIT-PLL

T-PLL

Largegranular lymphocytic leukemia:T-cell type and NK-cell type

T-cell granularlymphocytic leukemia Aggressive NK-cell leukemia

Small cell cerebriform(mycosis Mycosis fungoides, Sezary fungoides, Sezary syndrome) syndrome T-zone Lymphoepithelioid, PeripheralT-cell lymphomas, pleomorphic small T-cell, unspecified (including Pleomorphic medium-sized provisionalsubtype: and large T-cell, subcutaneouspanniculitic T-immunoblastic T-cell lymphoma)

Angioimmunoblastic (AIDL, LgX)

Pleomorphicsmall T-cell HTLVI Pleomorphicmedium-sized and large T-cell HTLVI + T-large cell anaplastic(Ki- 1+) +

Hepatosplenicy-6 T-cell lymphoma' AngioimmunoblasticT-cell lymphoma Angiocentriclymphoma

Mycosis fungoides, Sezary syndrome Peripheral T-cell lymphomas, not otherwise characterized

Subcutaneouspanniculitis-like T-cell lymphoma Hepatosplenic y 4 T-cell lymphoma

AngioimmunoblasticT-cell lymphoma

Nasal T-cell and NK-cell lymphoma Enteropathy-typeT-cell IntestinalT-cell lymphoma lymphoma (with or withoutenteropathy) Adult T-cell leukemia/ Adult T-cell leukemial lymphoma(HTLVI + ) lymphoma(HTLVI')

Anaplastic largecell lymphoma,T/null-cell types

Anaplastic large cell lymphoma, T/null-cell, primary systemic type Anaplastic large cell lymphoma,T/null-cell, primarycutaneoustype

"Bold letters representthe most common subtypes.

bProvisionalentity.

T-cell Large Granular Lymphocyte Leukemia T-cell large granularlymphocyteleukemia (T-LGL)is a heterogeneousdisordermostly followingan indolentclinicalcourse.Clonalkaryotypicabnormalitieshavebeen reportedin only very few cases, some of whichmightnot constituteT-LGLbutratherT-PLL,T-ALL,or hepatosplenicT-cell lymphoma.No consistentchromosomalchangeshave been identified

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MATURE6-AND T-CELLNEOPLASMS AND HODGKINLYMPHOMA

TABLE 10.7 Overview of Frequent and Diagnostically Relevant Chromosomal Aberrations in Mature TmK-Cell Neoplasms‘ Neoplasm

Cytogenetic Aberration

%

T-cell prolymphocyticleukemia

i(8q) or t(8;8)(p23;ql I ) or t 8 inv(l4)(ql lq32), t( 14;14)(q32;q1I ) t(X;14)(q28;q11) del(6q), del( I I q) 9q3 1 -qter del( 16q12) i(7q) +8 t(2:5)(p23;q35)and variants + X , f 7 , +9, -Y, del(6q), del(l7p) t/der(l4q32), t/der(1% 1 1 ), del(6q) t7/7q, t lq, +3p, f5p. f8q24 del(W, del(l0p) f 3 t x , f5/5q +21, +3q, del(6q)

6&90% 4&75% <2% 1&20% 70% 23% >70% >50% 40-90% 10-30% 30-50% 2&35% 20-30% 50-80% 20-55% 2 M %

+

Enteropathytype T-cell lymphoma HepatosplenicT-cell lymphoma Anaplastic large cell lymphoma Adult T-cell lymphoma/leukemia(HTLVI ) Peripheral T-celllymphomas,NOC +

AngioimmunoblasticT-cell lymphoma

“Only lymphomaswith sufficientcytogeneticdata are includedto estimatefrequencies.

thoughthereis some evidenceforbreakpointsin regionscontainingTCR loci, thatis, 7p, 7q, and 14qll.Deletion 6q has been reportedas the only recurrentchange(Man et al., 2002).

Natural Killer (NK)-Cell Leukemias and Lymphomas Severallymphomaand leukemiatypes are supposedto derive from a proliferationof NKcells. These include aggressiveNK-cell leukemia,extranodalNWT-cell lymphomaof the nasal type, and blastic NK-cell lymphoma. All of them are rare with some geographic variation.ExtranodalNWT-cell lymphomaof the nasal type is almost always associated with EBV infection. No specific chromosomalalterationhas yet been identifiedin these diseases. A variety of clonal cytogenetic aberrationshas been reported,of which del(6q) may be the most common. CGH studies have shown frequentdeletions at 6q16-27, 13q14-34, 11q22-25, and 1 7 ~ 1 3loss , of the whole X chromosome, as well as DNA amplificationsin NK-cell leukernidlymphoma.Recurrentgains were seen at 1p32-pter.6p, 1 lq, 12q, 17q, 19p,20q, and Xp (Siu et al., 1999). Mao et al. (2003b) reportedsimilar patternsof chromosome imbalances in both blastic NK and cutaneous NK-like T-cell lymphomas.The most frequentDNA copy numberchangeswere losses of 9/9p (83%)followedby loss of 13qand gain of 7 (67%).A recentarrayCGH study identifiedgain of lq23.1-24.2 and lq3 I .3-44 as well as loss of 7~15.1-22.3 and 17pI 3.1 as recurrentandcharacteristicof the aggressive NK-cell leukemiagroupcomparedwith those of extranodalNWT lymphoma,nasal type, Recurrentchangescharacteristicof the extranodalNK/T lymphoma,nasaltype compared with those of the other group, were gain of 2q and losses of 6q16.1-27, I lq22.3-23.3, 5~14.1-14.3, 5q34-35.3, 1~36.23-36.33, 2~16.1-16.3, 4q12, and 4q31.3-32.3 (Nakashima el al., 2005).

MATURE T-CELL AND NK-CELL NEOPLASMS

337

Enteropathy-Type T-cell Lymphoma Enteropathy-typeT-cell lymphoma (ETL) is a tumor of intraepithelialT-lymphocytes with a clear association with celiac disease (Jaffe et al., 2001). No specific cytogenetic aberrationshave been identified in the few cases subjected to chromosome banding analysis. ChromosomalCGH studies have revealed chromosomalimbalances in 87% of the cases analyzed with recurrentgains from 9q (58%), 7q (24%), 5q (18%), and Iq (16%) and 9p (18%). Array comparativegenomic and losses from 8p (24%). 13q hybridizationstudies have confirmed that ETL is characterizedby frequent gains of 9q31.3-qter(70%) and loss of 16q12.1 (23%); the two rarely occurredtogether.Two distinctgroupsof ETL were delineatedby Zen1 et al. (2002), Baumggrtneret al. (2003), and Deleeuw et al. (2007): (1) Type I ETL was linked pathogeneticallyto celiac disease and characterizedcytogeneticallyby gains of Iq and 5q; and (2) Type 2 ETL frequently showed gains of the MYC oncogene locus and, more rarely,from chromosomearms Iq and 5q.

(a%),

HepatosplenicT-cell Lymphoma HepatosplenicT-cell lymphoma is a neoplasm derived from cytotoxic T-cells usually of gammddeltaT-cell receptortype. An i(7)(qlO) or rare variantswere present in the vast majority of cases studied so far and are supposed to be the primary genetic change, frequentlyaccompaniedby trisomy 8 (Jonveauxet al., 1996; Wlodarskaet al., 2002).

Anaplastic Large Cell Lymphoma Anaplastic large cell lymphoma (ALCL) is a T-cell lymphoma consisting of CD30 (Ki-1)-positive tumor cells with variable morphologic features. The majorityof cases express the anaplasticlymphomakinase gene due to fusion of this gene with one of the several known partners.Therefore,ALK-positiveand ALK-negativeALCL are distinguished with the former being associated with a more favorable prognosis (Jaffe et al., 2001). This difference in outcome might be due to the fact that the median age of patientswith ALK-positiveALCLis lower thanthatof patientswith ALK-negative disease. According to the 2001 WHO classification,92%of ALCL in childrenare ALKpositive comparedwith only 72% of ALCL in adults (Jaffe et al., 2001). The updated WHO classification 2008 treats ALK-positive ALCL as a separate entity (Savage et al., 2008; Swerdlow et al., 2008). Morganet al. (1986) analyzedfour cases of what was diagnosedas malignanthistiocytosis and found in threeof them a t(2;5)(p23;q35).Laterstudiesshowed thatthe t(2;5)carryingtumorsactuallyare high-grade,anaplasticlarge-cell lymphomasthatexpressthe CD30 (Ki-1) antigen and which, consequently,are often referredto as Ki-1 lymphomas. Many of the tumorshave shown evidence of T-lineagedifferentiation,whereassome lack obviousT-cell markersbutare neverthelessderivedfromT-cells. Morriset al. ( I 994) as well as other investigatorsshowed the molecularconsequencesof the translocationto be the fusionof a nucleophosmingene, NPM,in band5q35 with the anaplasticlymphomakinase gene,ALK, in 2p23 leadingto a chimericproteinwith constitutivetyrosinekinaseactivity. Withthe availabilityof anti-ALKantibodiesit could be shown that the NPM-ALK fusion

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MATUREB- AND T-CELLNEOPLASMS AND HODGKINLYMPHOMA

protein is expressed in the cytoplasmbut also often in the nucleus. Up to 20% of ALKpositive ALCL lacked nuclearreactivityof the ALK-antibodybut insteadshowed various patternsof cytoplasmicand membranousstaining. In the course of these investigations, variantsof the t(2;5) were identifiedthat fused the ALK gene to otherpartners.The most frequentof these variantswas t(1;2)(q21-25;p23) fusingALK to TPM3.Less frequentare t(2;3)(p23;q12) leadingto TFG-ALK fusion, inv(2)(p23q35)leadingto ATIC-ALK fusion, t(2;17)(p23;q23) leading to CLTC-ALK fusion, t(X;Z)(glI;p23) leading to MSN-ALK fusion, t(2;17)(p23;q35)leading to AL017-ALK fusion, and t(2;22)(p23;qll) leading to MYH9-ALKfusion (Mitevetal., 1998;Hernhndezet al., 1999;Lamantet al., 1999a, 1999b; Ma et al., 2000; Touriolet al., 2000; Tortet al., 200 1 :Cools et al., 2002). It can be anticipated that additionaltranslocationsinvolving the ALK gene in 21323 exist in ALCL. Secondarychromosomalchanges in ALCL are not well studied,but in smallerseries gains of chromosomes 7, 9, and X and losses of Y, 6q, and 17p have been reported (Johanssonet al., 1995; Weisenburgeret al., 1996). In a recent study using chromosomal CGH,ALK-positiveALCLwith NPM-ALK or ALK varianttranslocationsshowed similar profilesof secondarygenetic alterations. As to therecentdistinctionbetweenALK-positiveandALK-negativeALCLas well as the problemof unequivocallydifferentiatingthe latterdisease fromotherlymphomasubtypes, hardlyany reliablecytogenetic dataon ALK-negativeALCL are at hand to help. Nelson et al. (2008) describedgainsof Iq (50%)and3p (30%)and losses of l6pter(50%), 6q13-21 (30%),15 (30%),16qter(30%),and l7p I 3 (30% ) asbeingfrequentin ALK-negativeALCL. CGHshowed ALK-positiveand ALK-negativeALCLto havedifferentsecondarygenomic aberrations,suggestingthatthey correspondto differentgenetic entities.Gains of 17p and 17q24-qterand losses of 4q13-21 and I lq 14 were associatedwith ALK-positivedisease, whereas gains of lq and 6p21 were more frequentin ALK-negativeALCL. Gains of chromosome7 and 6q and 13q losses were seen in both types (Salaverriaet al., 2008). Zettlet al. (2004)also reportedALK-negativeALCLtodisplayrecurrentchromosomalgains of Iq (lq41-qter,46%)andlossesof6q(6q21,3l%)and13q(13q21-22,23%).However,no specific chromosomalalterationswere associatedwith survival. PrimarycutaneousCD30-positiveT-cell Iymphoproliferative disordersincludeprimary cutaneousALCL and lymphomatoidpapulosis.The formermostly and the latteralways lack t(2p23) or its molecular counterpartALK fusion genes and in general show few recurrentchromosomalimbalances(Jaffe et al., 2001). By CGH, the mean numberof changes in nonrelapsingdisease has been reportedto be only 0.33 (range&I), compared with 6.29 (range 1-16) in relapsing disease. Chromosomes often found affected by aberrationsin relapsingdisease have been 6 (86%), 9 (86%), and 18 (43%). Whereas chromosome9 was mostly affectedby gains,chromosomes6 and 1 8 mainlyshowedregions of loss, especially from 6q and 18p. Common regions of loss were 6q21 and 18~11.3 (Prochazkovaet al., 2003).

Peripheral T-cell Lymphoma, Unspecified PeripheralT-cell lymphoma,unspecified (PTCL-US) collectively refers to a numberof distinct entities defined by former classifications, such T-zone, lymphoepithelioid (Lennert), small, medium-sized, and large cell pleomorphic T-cell lymphoma, and T-immunoblasticlymphomaaccordingto the Kiel classification(Jaffeet al., 2001). These tumorsaccountfor approximatelyhalf of the peripheralT-cell lymphomasseen in Western countries.

MATURET-CELLAND NK-CELLNEOPLASMS

339

In contrastto whatis the situationin precursorT-cell neoplasms,translocationst( 14qll), t(7q34), and t(7p14) involving the TCR gene loci are widely absent in PTL (Lepretre et al., 2000; Leichet al., 2007). The notableexceptionis t(14;19)(qIl;q13)thatrecurrently translocatesPVRL2 to the TCRA locus in rare cases of PTCL-US, includingLennert’s lymphoma(Almireet al., 2007; Leich et al., 2007). The molecularconsequencemight be activationof the BCW gene in proximityto the breakpointin 19q13. Anotherrecurrent translocationin PTCL-USis t(5;9)(q33;q22)resultingin ITK-SYK fusion. Streubelet al. (2006b) detectedITK-SYK fusion transcriptsin 5 of 30 (17%)unspecifiedPTCLbutnot in cases of angioimmunoblasticT-cell lymphoma(AILT) (n = 9) and anaplasticlymphoma kinase-negativeanaplasticlarge-celllymphoma(n = 7). Remarkably,threeof the five t(5;9) (q33;q22)-positiveunspecified PTCL shared a very similar histological pattern with predominantinvolvement of lymphoid follicles and the same CD3 CD5 CD4 bcl-6 CD 10 immunophenotype. Like in otherAILTandALK-negativeALCL,cytogeneticcorrelationshavenot yet come acrossas very characteristic.Nelson et al. (2008) reportedfrequentgainsinvolving7q22-3 I (33%), Iq (24%), 3p (20%),5p (20%),and 8q24-qter(22%)but losses of 6q22-24 (26%) and lOpl3-pter(26%)in PTCL-US.A comparablespectrumof imbalanceswas reportedby Schlegelbergeret al. (1994a, 1994b) and Lepretreet al. (2000). In 36 de novo PTCL-US, Zettl et al. (2004) identifiedby CGH recurrentchromosomallosses from 13q (minimally overlappingregion 13q2I , 36%of cases), 6q and9p (6q21 and9p21-pter,in 3 1%each), 1Oq and 12q (1 Oq23-24 and 12q21-22, in 28%each),and5q (5q21,25%).Recurrentgains were seen of 7q22-qter (31%). In 1 I PTCL US, high-level amplifications were observed, includingthree cases with amplificationof 1 2~ 1 3Thorns . et al. (2007) used aCGH to examine20 PTCL-USfindinggainsof orfrom 17 (17ql1-25), 8 (involvingtheMYClocusat 1 8q24), 1 I q 13, and 22q and losses of or from 13q, 6q (6ql6-22), 1 1 pl 1, and 9 ( 9 ~ 2 -q33). Interestingly,gains of 4q (4q28-3 1 and 4q34-qter),8q24, and 17 were significantlymore frequentin PTCL-USthan in AILT. No conclusive correlationshave been found between the cytogenetic findings and histologic subgroups or clinical outcome in PTCL-US as yet. Schlegelbergeret al. ( 1994b) observedtrisomy 3 only in T-zone lymphomaand lymphoepithelioidlymphoma accordingto the Kiel classification.Zettlet al. (2004) reportedhigh-level amplificationsof 1 2 ~ 1 3to be restrictedto cytotoxic PTCLNOS.

+

+

+

+

+

AngioimmunoblasticT-cell Lymphoma AngioimmunoblasticT-cell lymphomaaccountsfor 1 5 2 0 %of peripheralT-cell lymphomas. It was initially felt to be an atypical reactive process, angioimmunoblasticlymphadenopathy(AILD), with an increased risk of progressionto lymphoma.Atypical and oligoclonalproliferationsmay precedethedevelopmentof lymphoma.EBV canbe detected in more than 75% of AILT (Jaffeet al., 2001). A cytogeneticfeaturecharacteristicof AILTareunrelatedclones, which can be found in 15%of cases (Kanekoet al., 1988;Schlegelbergeret al., I994a, 1994b).Trisomy 3, trisomy 5, and + X predominate(Kaneko et al., 1988; Schlegelberger,1994a, 199413, 1994d; Lepretreet a]., 2000). Using interphasecytogenetics,Schlegelbergeret al. ( 1 9 9 4 ) found that78% of AILTshowed 3 clones and 34% showed X clones. These frequenciesfar exceeded those observed with metaphasecytogenetics ( + 3 , 41%; +X, 20%) and may possibly representan overestimatebased on the applied cutoff levels for diagnosing alterationsby FISH. Nelson et al. (2008) reportedthat the most common abnormalities

+

+

WO

MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

in AILTweregainsof orfrom5q (55%),2 1 (4 I %), and3q (36%),trisomiesof chromosomes 5 and 21 (41%).and loss of 6q (23%).TranslocationsaffectingTCR loci arewidely absent (Gesket al., 2003; Leichet al., 2007). Using aCGH,Thornset al. (2007) foundthatthe most commonchangesinAILTweregainsof22q, 19,and 1 lpll-q14(1 lq13),andlossesof 13q. Trisomies3 and 5 were identified in only a small numberof cases.

Clinical Correlations in AlLT Schlegelbergeret al. (1996) reportedpresence of abnormalmetaphasesin unstimulatedcultures,clones with X, structuralaberrationsof the short arm of chromosome 1 (lp31-32), and complex clones with more than four aberrationsto be associated with a significantly lower incidence of therapy-induced remission and a significantly shortersurvival. Multivariate analysisshowed that these cytogeneticfindingshad a significantinfluenceon survival,whereastherapymodalitiesdid not. Only the presenceof complex aberrantclones was an independentprognosticfactor. Trisomy3 had no effect on survival.

+

Mycosis Fungoides and Sezary Syndrome Mycosis fungoides(MF) is the most common subtypeof the T-cell lymphomasthat arise primarilyin the skin.It is a matureT-cell lymphomapresentingwith patches/plaquesandis characterizedby a dermalinfiltrationof small- to medium-sizedT-cells with cerebriform nuclei. Sezarysyndrome(SS) is a generalizedmatureT-cell lymphomacharacterized by the presenceof erythroderma, lymphadenopathy, andneoplasticT-lymphocytesin theblood.It is regardedas a variantof MFthoughits behavioris usuallymoreaggressive(Jaffeet al., 2001 ). Chromosomebandingdataon both these cutaneousT-cell lymphoma(CTCL)arestill limited with karyotypes available on only about 150 cases (Mitelman et al., 2008). Chromosomeabnormalities,mostly in complex karyotypes,areseen in 40-70% of patients with MF/SS, but there have only been a few instances of recurrentrearrangements (Schlegelbergeret al., 1994a, 1994b, 1994d;Mao et al., 2003a; Espinetet al., 2004; Batista et al., 2006). The karyotypesin almost all cases are highly complex and evidence of chromosomalinstabilitycan be seen. MonosomyI0 has been reportedas the most fiequent cytogeneticchange(73%of abnormalcases). Monosomy 9 and trisomy 18 have also been recurrentlyobserved.The chromosomesmost frequentlyinvolved in structuralaberrations havebeen 1,6,8,9,10,1 I, and 17. Recurrentbreakpointshavebeenseen in 1p32-36,l q, 2q, 6q22-27, 8q22, 17pI 1.2-13, lOq23-26, and 19~13.3.The aberrationsdic(17;8)(p11.2; pl 1.2), der(1)t(l; IO)(p2;q2),and der(14)t(l4q; 15q) might be recukentin MF/SS, whereas translocationsaffecting TCR loci seem to be absent. Karenkoet al. (2005) identified common clonal deletions or translocationswith a breakpointin 12q21or 12q22in SS. These seem to targetthe NAV3 (POMFILI)gene for inactivation.With locus-specific FISH, NAV3 deletions were found in the skin lesions of 4 of 8 (50%)patientswithearlyMF andin the skinorlymphnodesof 11of 13(85%)patients with advancedMFor SS. CGHstudieshave revealedcommonlosses of orfrom 1p. 6q, lOq, 13q, 17p,and 19 and gains of or from 7,8q, 17q, and 18 (Ma0 et al., 2002,2003a; Fischer et ai., 2004). The pattern-6q, +7, +8, and -13 was the most frequentcombinationof imbalances. Chromosomalaberrationsare morecommon in advancedand aggressivedisease stages and subtypes.A high numberof aberrations,gain of 8q, and loss of 6q and 13q have been associated with shortersurvival(Fischeret al., 2004).

MATURE T-CELL AND NK-CELL NEOPLASMS

341

The spectrumof cytogeneticchanges in subcutaneous panniculitis-like T-cell lymphomas (SPTL),a rare,difficult-to-diagnose,and poorly characterizedsubtypeof CTCL,has

recently been shown by CGH to overlapwith those characteristicof MM and SS. Many DNA copy numberchangeswereidentified,themostcommonof which werelosses of 1pter, 2pter, 1Oqter, 1 1qter. 12qter,16,19,20, and 22 and gains of 2q and 4q. NA V3 aberrations were identifiedin 44%of the SPTLsamples.Gainsof orfrom 5q and 13q may characterize SPTL (Hahtolaet al., 2008).

Adult T-cell Leukemia/Lymphoma (ATLL) AdultT-cell 1eukemiaAymphoma (ATLL)is a usuallywidely disseminatedperipheralT-cell neoplasm. ATLL is endemic in several regions of the world, in particularJapan, the Caribbeanbasin,andpartsof CentralAfrica.Thedistributionof thediseaseis closely linked to the prevalenceof humanT-cell leukemiavirus-I (HTLV-l), which is found in all cases and is supposedto be causativefor the disease (Jaffeet al., 2001). Chromosomeabnormalitieshave been found in more than 90% of the ATLL patients examined.Althoughthe changesareoftenbothcomplexandvariable,they areundoubtedly nonrandom.Aneuploidy and multiplebreaksare observedfrequentlyin acute and lymphomasubtypesof ATLL(Kamadaetal., 1992;Itoyamaetal., 2001). Chromosome14 is the one most frequentlyrearranged,often as t(14;14)(qll;q32), inv(l$)(ql lq32), and del(14) (ql Iq13) orrecombining14qI 1withseveralotherchromosomearms,includingXq, lp, lq, 3p, 3q, 8q, lop, l l p , 12q, and 18p. t(14;14)(qll;q32)has been shown to involve the TCRAD and BCLllB genes in at least one case suggesting general involvementof the TCR loci (Przybylski et al., 2005). Furthermore,CGH has identified common 14q32 gaidamplificationassociatedwith BCLllB overexpression(Oshiroet al., 2006). The most frequentlydetected other imbalanceswere gains of 7q and 3p and losses of 6q and 13q (Tsukasakiet al., 2001; Oshiroet al., 2006). Comparisonof the genome profiles of acute and lymphomatypes of ATLL detected by CGH revealed that the lymphoma type more frequentlyhad gains from Iq, 2p, 4q, 7p, and 7q and losses from lop, 13q, 16q, and 18p, whereasthe acute type showed gain of 313~.Recurrenthigh-level amplificationswere found at lp36, 6p25, 7p22, 7q, and 14q32 in the lymphoma type, with CARD11 being a candidate oncogene in 7p22 (Oshiroet al.. 2006). Numerousotherchromosomalregions have also occasionally been involved in ATLL, including lp, lq, 3q, 5p, 5q, 9q, lop, IOq, 1 Iq, 12q, 18q, and Y. A del(6q) with breakpointsmostly localized to bands q15 and q21 is seen in 25% of ATLL patients, mostly together with changes of 14qlI and/or 14q32. Altogether, aberrationsaffecting 14ql1, 34q32, and/or 6q are seen in half of all karyotypically abnormalATL.

Clinical Correlations in ATLL Aberrationsof lp, Iq, lqI0-21, lop, lOp13, 12q, 14q, and 14q32 have been reportedto correlatewith clinical features like hepatosplenomegaly, elevated lactate dehydrogenase,hypercalcemia,and an unusualimmunophenotype, all indicatorsof clinical seventy in ATLL. Multiplechanges,abnormalitiesof Ip, lp22, lq, lql0-21, 2q, 3q, 3q10-12, 3q21, 14q, 14q32, and 17q, and partiallosses from chromosome arms 2q, 9p, 14p, 14q, and 17q have correlated with shorter survival (Itoyamaet al., 2001).

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MATURE B- AND T-CELLNEOPLASMS AND HODGKINLYMPHOMA

HODGKIN LYMPHOMA Hodgkin lymphomarepresentsa peculiarsubtypeof mostly B-cell lymphoidmalignancy that has been classified into two main subtypes,classical HL and the more rare nodular lymphocytepredominanceHL,(nlpHL).One of the main featuresof HL is thatthe tumor parenchymacells only represent0.1-10% of the total even in representativesamples,the rest derive from an intenseinflammatoryreaction.Therefore,the cytogeneticexamination of HL is very challengingandfrequentlyrendersnormalkaryotypesthatarerepresentative only of the abundantnonmalignantcells. When the chromosomeanalysis is informative, karyotypesare very differentfrom those of NHL (Drexler,1992; Atkin, 1998).

Classical Hodgkin Lymphoma (cHL), Including the Subtypes Nodular Sclerosis, Lymphocyte-Rich, Mixed Cellularity, and Lymphocyte-Depleted Chromosomeanalysesin many cHL revealonly normalkaryotypesderivedfromthe nonneoplastic bystandercells. A subset of cases particularlyin earlier studies also showed single or few aberrations,which nowadaysare supposednot to be derivedfrom the tumor parenchyma.Theapplicationof chromosomebandinganalysisand interphaseFISHstudies in combinationwith CD30-immunofluorescence staininghas unambiguouslyshownthat,in most instances,the neoplastic HodgkidReed-Sternberg(HRS) cells of classical HL are characterizedby highly complex karyotypeswith evidence of ongoing chromosomal instability (i.e., each metaphasemay be cytogeneticallydifferent),modal chromosome numbers mostly in the tri- or tetraploidrange, multiple aneuploidies,and segmental chromosomeaberrations(Drexler, 1992; Schlegelbergeret al., 1994c; Weber-Matthiesen et al., 1995; Atkin, 1998; MacLeod et al., 2000; Joos el al., 2003; Martin-Subero et al., 2003a). Usually the karyotypeis not fully resolvable.Falzettiet al. (1999) reviewed the karyotypesof 177 cHL andpointedto some clonal nonrandomchanges.Breakpointsin 1 p36,6q15-12,7q22-32,8q24,1 lq23,12q24, I4q32, and 19p13 were presentin morethan 5% of cases. Moreover,the short a n n s of the acrocentricchromosomeswere recurrently involved in translocationssuggesting a pathogeneticrole of instabilityat rRNA loci. Recurrentdeletionsof 6q are seen and the TNFAIP3 gene has been suggested to be targetedby these deletionswith concomitantmutationsof the second allele in roughlyhalf of the cases (Giefinget al., 2008; Hartmannel al., 2008). Othertumorsuppressorgenes inactivatedin cHLareparticularlyIKBA in 14qandSOCSZ in 16pI3 (Cabanneset al., 1999; Emmerichet al., 1999; Jungnickelet al., 2000; Wenigeret al., 2006; Mottokel al., 2007). Recent molecularcytogenetic studies demonstratedthat t( 14q32) involving the IGH locus are present in 1.5-2070 of cHL (Martin-Suberoet al., 2006). The partnersof these translocationsareheterogeneous,including2p16 (REL), 3q27 ( B C B ) ,8q24 (MYC), 14q24, 17q12,and 19q13(BCW)(Martin-Suberoetal., 2006; Szymanowskaetal., 1 6 ~ 1 (C2TA), 3 2008). Translocationst( 14;18)(q32;q2I ) or t(3q27) occurextremelyrarelyin cHL with the exceptionof compositecHL and NHL lymphomas,in which the HRS cells regularlycarry the typical primarychromosomalalterationof the respectiveNHL (Schmitzet al., 2005; Szymanowskaet al., 2008). CGH of DNA from microdissectedH R S cells has identified gains of chromosomal material(e.g., duplicationsor amplifications)in 2p13-16 (affectingthe REL oncogene) in 40-50% of the cases and in 9p24 (possibly targetingJAK2, PDLI, and PDL2) in 3040% (Joos et al., 2000,2002; Martin-Suberoet al., 2002). With regardto 2p, it'hasbeen shown thatHRScells with extracopies of theREL gene may haveaccumulationof the RELprotein

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in the nucleus(Barthet al., 2003), which might accountfor the characteristicREL/NF-kB activationobservedin HRS cells (Bargouet al., 1996).

Nodular Lymphocyte Predominant Hodgkin Lymphoma NodularlymphocytepredominantHodgkinlymphomasharesmany featureswith DLBCL and may indeedbe a NHL ratherthan a HL. Correspondingly,the scarcecytogeneticdata suggest the presenceof similarchromosomalaberrationsin nlpHL to those of DLBCL. Using cytogeneticandmolecularcytogenetictechniques,t(3q27)involvingthe BCM locus have been reportedin up to 50%of the cases (Wlodarskaet al., 2003; RennBet al., 2005). The3q27-rearrangements as usualincludet(3;24)(q27;q32)withits light-chainvariantsbut also involve non-IGloci as translocationpartners. Practicallyno informationis available about the prognosticimpact of chromosomal findingsin HL, particularlyif modem therapieswith a high likelihood of cure are being considered.One CGHstudiedhasassociateddel( 13q)with unfavorablediseaseoutcomein cHL (Chui et al., 2003).

CLINICAL CORRELATIONS The cytogeneticchanges in maturelymphoidneoplasmsand theirclinical impactgreatly depend on the disease subtype in which they occur. They have thereforemostly been discussed in the respectivedisease-specificsections. The most importantclinicalreasonfor identifyingchromosomalaberrationsin suspected maturelymphoidneoplasmsis the fact that they provideessential informationon which a correct, precise diagnosis can be based. Different histopathologic subtypes of mature lymphoid neoplasms are associated with very different naturalcourses and show quite differentresponsesto therapy.Modem therapyfor maturelymphoid neoplasmsrelies on the properclassificationof the lymphoma,and the patternsof both primaryand secondary chromosomalaberrationsconstitutepart of the foundationfor that classification.Indeed, comments on the 2001 WHO classification recommend that cytogenetic analysis be performedin all cases andshouldformpartof thepathologyreport(Harriset al., 1999,2000). It has to be emphasizedthat the same chromosomalaberrationsmay have different prognosticimpact in the various subtypesof maturelymphoidneoplasms. Among nonHodgkin lymphomas, for example, t( I 1 :14)(q13;q32) mostly signifies a mantle cell lymphomathat has a poor prognosis. In contrast,t(l1;14) in multiple myeloma defines a disease subsetwith a relativelyfavorableoutcome(thoughcomparedto t( 11;14)-positive MCL,the overallsurvivalof patientswith t( 1 1;14)-positiveMM is still worse). Moreover, t( 1 I ;14)canbe detectedin preneoplasticdisorderslike MGUSandin quiteindolentdiseases like SLVL. These findings point to the need to integratecytogenetic analysis into an interdisciplinarydiagnosticworkupof maturelymphoidneoplasms,which, besides histopathologic featuresand the immunophenotype,also takes into account both the clinical presentationand the neoplasticcells’ genetic characteristics.It can be anticipatedthat the diagnostic process will soon also see the integrationof findings made by array-based technologieslike gene expressionprofiling. Despite the fact that the clinical relevanceof cytogeneticchanges in maturelymphoid neoplasmsalwayshas to be evaluatedin the contextof the disease subtype,a few common themesgenerallyassociatedwith unfavorableoutcomeseem to exist: In most instancesof

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maturelymphoidneoplasms,the rule of thumbis thatthe morecomplex the karyotype,the worse is the prognosis.A notable exceptionhere is cHL that is characterizedby highly complex karyotypes,and yet long-term cure rates far exceeding 80% are reached with modemtherapy.Lossesof 17p and 9p aresupposedto mostly targetthe TP53and TPI6gene loci. One or both changes are associated with unfavorableoutcome in many mature lymphoid neoplasms, including CLL, FL, MCL, and DLBCL. Finally, translocations affectingthe band8q24 mostly targettheMYConcogene.In most typesof maturelymphoid neoplasms,includingFL.MCL,and DLBCL, these changesare associatedwith increased clinical aggressivenessand an unfavorableprognosis.The notableexceptionhere is BL in which t(8;14) and variantsare the pathognomonicalterations.Despite being a biologically highly aggressivedisease,BL can be cured in most instances,particularlyin children. The nearfuturewill see the increasingintroductionof molecularcytogenetictechniques like FISH and array CGH into the diagnosis of mature lymphoid neoplasms. Indeed, interphaseFISH is alreadywidely used for the diagnosisof the most recurrentalterationsin CLLandMM andis also becominga routinetool forthe detectionof diagnosticallyrelevant chromosomalalterationsin formalin-fixed, paraffin-embeddedtissues (Ventura et al., 2006). Nevertheless, in contrastto chromosomebanding analysis, interphaseFISH will never provide a full overview of all chromosomalaberrationsof a mature lymphoid neoplasm. This carriesthe very real risk that clinically relevantalterations,like t(8q24) in t(l4;18)-positive FL, might be missed simply because they were not searched for. Moreover,a subclonewith prognosticallyunfavorablechromosomalaberrationsmay be missed by FISH,whereas it might be detected by conventionalcytogenetics due to a proliferativeadvantageof these cells. Finally,complex and variantFISH patternsmightbe difficult to interpretwithout knowledge of the metaphase chromosomalpicture, the karyotype. As briefly indicatedabove for some subtypesof maturelymphoidneoplasms,the advent of arrayCGHandrelatedtechniqueswill bringfortha wealthof new data,which in termsof size lie somewherebetween the cytogenetic and molecularresolutionlevels. One should exercise considerablecaution,however,when tryingto translatefindingsand conclusions between the microscopiccytogenetic and the array-basedinformationrealms. As can be seen from the discussion above of 13q deletions in MM, the diagnostic impact of a chromosomalchange may seeminglydependon the techniquewith which it was detected (Dewaldet al., 2005). Both small andlargegeneticchangescanbe missed if one exclusively relieson only one technique,not least if the changein questionis presentonly in a subclone. The results are invariably best if different techniques and investigative principles are allowed to complementeach other. It should finally be stressed that the treatmentof many maturelymphoidneoplasmsis now undergoingprofoundchanges. Probablythe most importantrecent improvementin the treatmentof the most common lymphomas,includingthe matureB-cell lymphomas MCL, FL, and DLCBL, was the introductionof anti-CD20 immunotherapy(rituxan). Almost all cytogenetic studies referredto above were performedbefore the introduction of this therapy, and we do not know whether the cytogenetic-prognostic correlations detectedduringthe pre-rituxanera still apply when the new antibodytreatmentis given. Indeed, with the exception of CLL and MM and in part BL, hardly any systematic cytogenetic studies within clinical trialsexist. This needs to be changedin futureso that cytogenetic studies form anessential and integralpartof prospectiveclinical trials;only then can the clinical impactof the variousacquiredgenomic changesin maturelymphoid neoplasms be reliably assessed.

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ACKNOWLEDGMENTS Theauthor’sown studieson chromosomalaberrationsin lymphoidneoplasmsaresupported by DeutscheKrebshilfe,WilhelmSander-Stiftung,KinderKrebsInitiative (KKI) Buchhold Holm-Seppensen,EuropeanUnion, LymphomaResearch Foundation(New York), and Schleswig-HolsteinischeKrebsgesellschaft.The author would like to thank Dr. JoseIgnacio Martin-Subero,Dr. Borja Saez, and Heike Blohm for editorialsupportand Dr. LanaHarder,Dr. Simone Heidemann,andClaus-PeterBlohm for providingthe figuresand the graphicaldesign. Finally, the authoracknowledgesall colleagues worldwidewho have made publiclyavailabletheircytogeneticdataon lymphoidneoplasmsandat the sametime apologizes to all those whose work could not be cited herein.

REFERENCES Aamot HV, Bjornslett M, Delabie J, Heim S (2005a): t(14;22)(q32;qlI ) in non-Hodgkin lymphoma and myeloid leukaemia: molecular cytogenetic investigations. Br J Haernutol 130:845-851. Aamot HV, Micci F, Holte H, Delabie J, Heim S (2005b): G-bandingand molecularcytogenetic analysesof marginalzone lymphoma.Br J Huemalo1 130:890-901. AamotHV, TorlakovicEE, Eide MB, HolteH,HeimS (2007): Non-Hodgkinlymphomawitht(14;18): clonal evolution patternsand cytogenetic-pathologic-clinicalcorrelations.J Cancer Res Cfin Oncol 133:455-470. Akagi T, Motegi M, TamuraA, SuzukiR, HosokawaY, SuzukiH, OtaH, NakamuraS, MorishimaY, TaniwakiM, Set0 M (1999): A novel gene, MALT1 at 18q21, is involved in t(11;18) (q21;q21) found in low-grade B-cell lymphoma of mucosa-associated lymphoid tissue. Oncogene 18:5785-5794. Aka0Y, Set0 M, YamamotoK, IidaS, NakazawaS, InazawaJ, AbeT,TakahashiT, Ueda R (I 992):The RCKgene associatedwith t(1 I ; 14)translocationis distinctfromtheMLL/ALL-I genewith t(4;I 1) and t( I 1;19) translocations.Cancer Res 52:6083-6087. AlizadehAA, Eisen MB. Davis RE, Ma C, Lossos IS, RosenwaldA, BoldrickJC,SabetH, TranT, Yu X, Powell JI, Yang L, Marti GE,Moore T, HudsonJ Jr,Lu L, Lewis DB, TibshiraniR,SherlockG, ChanWC, GreinerTC, WeisenburgerDD, ArmitageJO, Wamke R, Levy R, Wilson W,Grever MR, Byrd JC, Botstein D, Brown PO, StaudtLh4 (2000): Distincttypes of diffuse large B-cell lymphomaidentifiedby gene expressionprofiling.Nature 403:503-5 I 1. AlmireC, BertrandP, RuminyP, MaingonnatC, Wlodmka 1, Ma&-Subero JI, SiebertR, Tilly H, Bastard C (2007): PVRL2 is translocatedto the TRA@ locus in t(14;19)(q11;ql3)-positive peripheralT-cell lymphomas.Genes Chromosomes Cancer 46: 1011-101 8. AthanasiadouA, StamatopoulosK, TsompanakouA, GaitatziM, KalogiannidisP, Anagnostopoulos A, FassasA, Tsezou A (2006):Clinical,immunophenotypic, andmolecularprofilingof trisomy12 in chronic Iymphocyticleukemia and comparisonwith other karyotypicsubgroupsdefined by cytogenetic analysis. Cancer Genet Cytogenet 168:109-1 19. Atkin NB (1998): Cytogeneticsof Hodgkin’sdisease. Cytogenez Cell Genet 8023-27. Au WY, GascoyneRD, ViswanathaDS. SkinniderBF, ConnorsJM, Klasa RJ, HorsmanDE (1 999): Concurrentchromosomal alterationsat 3q27, 8q24 and 18q21 in B-cell lymphomas. Br J Haematol 105:437-440. Au WY, Horsman DE, Viswanatha DS, Connors JM, Klasa RJ, Gascoyne RD (2000): 8q24 translocations in blastic transformation of mantle cell lymphoma. Haematologica 85: 1225-1 227.

346

MATURE 0- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

Au WY, Gascoyne RD, ViswanathaDS. ConnorsJM, Klasa RJ, HorsmanDE (2002): Cytogenetic analysis in mantle cell lymphoma:a review of 214 cases. Leuk Lymphoma 43:783-791. Au WY, HorsmanDE, Gascoyne RD, ViswanathaDS. KlasaRJ,ConnorsJM(2004): The spectrumof lymphomawith 8q24 aberrations:a clinical, pathologicaland cytogenetic studyof 87 consecutive cases. Leuk Lymphoma 4 5 5 19-528. Austen B, Skowronska A, Baker C, Powell JE. Gardiner A, Oscier D. Majid A. Dyer M, Siebert R, Taylor AM, Moss PA, Stankovic T (2007): Mutation status of the residual ATM allele is an important determinantof the cellular response to chemotherapy and survival in patients with chronic lymphocytic leukemia containing an 1 lq deletion. J Clin Oncol 255448-5457. Avet-Loiseau H, Andree-AshleyLE, Moore D 2nd, Mellerin MP, FeusnerJ, Bataille R, Pallavicini MG (1997): Molecular cytogenetic abnormalities in multiple myeloma and plasma cell leukemia measured using comparative genomic hybridization. Genes Chromosomes Cancer 19:124- 133. Avet-Loiseau H, Li JY, Facon T, Brigaudeau C, Morineau N, Maloisel F, Rapp MJ, Talmant P, TrimoreauF, Jaccard A, HarousseauJL, Bataille R (1998): High incidence of translocations t( 11; 14)(q13;q32) and t(4;14)(p16;q32) in patients with plasma cell malignancies. Cancer Res 58:564&5645. Avet-Louseau H, Daviet A, Sauner S, Bataille R, IntergroupeFrancophonedu MyClome (2000): Chromosome 13 abnormalitiesin multiple myeloma are mostly monosomy 13. Br J Haemalol Itl:l116-1117. Avet-Loiseau H, Gerson F, Magrangeas F, Minvielle S, Harousseau JL, Bataille R, Intergroupe Francophonedu MyClome(2001): Rearrangementsof the c-myc oncogene are presentin 15%of primaryhuman multiple myeloma tumors. Bfood 98:3082-3086. Avet-LoiseauH, Facon T, GrosboisB, MagrangeasF, RappMJ, HarousseauJL,Minvielle S, Bataille R, IntergroupeFrancophonedu Myelome (2002): Oncogenesis of multiple myeloma: 14q32 and 13q chromosomalabnormalitiesare not randomly distributed,but correlatewith naturalhistory, immunological features, and clinical presentation.Blood 99:2185-219 1. Avet-Loiseau H, Attal M, Moreau P, CharbonnelC, Garban F, Hulin C, Leyvraz S, Michallet M, Yakoub-Agha 1, Garderet L, Marit G, Michaux L, Voillat L, Renaud M, Grosbois B, Guillerm G, Benboubker L, Monconduit M, Thieblemont C, Casassus P, Caillot D, Stoppa AM, Sotto JJ, Wetterwald M, Dumontet C, Fuzibet JG, Azais 1, Dorvaux V, Zandecki M, Bataille R, Minvielle S, Harousseau JL, Facon T, Matbiot C (2007): Genetic abnormalities and survival in multiple myeloma: the experience of the Intergroupe Francophone du Myelome. Blood 1093489-3495. Banks PM, Chan J, Cleary ML, Delsol G, De Wolf-Peeters C, Gatter K, Grogan TM, HarrisNL, Isaacson PG, Jaffe ES,et al. (1992): Mantle cell lymphoma. A proposal for unification of morphologic, immunologic, and moleculardata. Am J Surg Patho/ 16637-640. BargouRC, Leng C, KrappmannD, EmmerichF,MaparaMY, BommertK, Royer HD, ScheidereitC, Dorken B (1996): High-level nuclear NF-kappa B and Oct-2 is a common feature of cultured Hodgkin/Reed-Stemberg cells. Blood 87:43404347. Barille-Nion S , Barlogie B, Bataille R, Bergsagel PL, EpsteinJ, Fenton RG, JacobsonJ, KuehlWM, Shaughnessy J, Tricot G (2003): Advances in biology and therapy of multiple myeloma. Hematology (Am Soc Hematol Educ Program) 248-278. Bar6C, Salido M, Doming0 A, GranadaI, Colomo L, SerranoS, Sole F (2006): Translocationt(9; 14) (p 13;q32) in cases of splenic marginalzone lymphoma.Haematologica 91: 1289-1 291. BarthTF,Bentz M, LeithauserF, StilgenbauerS, Siebert R, Schlotter M, Schlenk RF, Diihner H, Moller P (200 1): Molecular-cytogeneticcomparisonof mucosa-associatedmarginalzone B-cell lymphomaand large B-cell lymphomaarising in the gastro-intestinaltract.Genes Chromosomes. Cancer 31:316-325.

REFERENCES

347

BarthTF, Martin-SuberoJI,Joos S, Menz CK, Hasel C, MechtersheimerG,ParwareschRM, LichterP, Siebert R, Mooller P (2003):Gains of 2p involving the REL locus correlatewith nuclearc-Re1 protein accumulationin neoplastic cells of classical Hodgkin lymphoma.Blood I01:3681-3686. Bhecke J, Griesinger F, Triimper L, Brittinger G (2002):Leukemia- and lymphoma-associated genetic aberrationsin healthy individuals.Ann Hematol8 154-75. Batista DA, VonderheidEC, Hawkins A, MorsbergerL, Long P, MurphyKM, Griffin CA (2006): Multicolor fluorescence in situ hybridization(SKY) in mycosis fungoides and SCzarysyndrome: search for recurrentchromosome abnormalities.Genes Chromosomes Cancer 45:383-391. BaumgartnerAK, ZettlA, ChottA, OttG, Miiller-HermelinkHK, StarostikP (2003):High frequency of genetic aberrationsin enteropathy-typeT-cell lymphoma. Lab Invest 83:1509-1516. Bea S , L6pez-GuillermoA, Ribas M, Puig X, Pinyol M, Cani6 A, Zamora L, Soler F, Bosch F, Stilgenbauer S, Colomer D, Mir6 R, MontserratE, Campo E (2002): Genetic imbalances in progressed B-cell chroniclymphocytic leukemiaand transformedlarge-cell lymphoma(Richter’s syndrome). Am J Pathol 161:957-968. Bea S, Zettl A, WrightG, SalavemaI, Jehn P, Moreno V, BurekC, Ott G, Puig X, Yang L, LopezGuillermoA, ChanWC, GreinerTC, WeisenburgerDD, ArmitageJO,GascoyneRD, ConnorsJM, GroganTM, Braziel R, FisherRI,Smeland EB, Kvaloy S, Hoke H, Delabie J, Simon R, Powell J, Wilson WH, Jaffe ES, MontserratE, Muller-HermelinkHK, StaudtLM, CampoE, RosenwaldA, LymphomdLeukemiaMolecular Profiling Project (2005):Diffuse large B-cell lymphoma subgroups have distinct genetic profiles that influence tumor biology and improve gene-expressionbased survival prediction. Blood 106:318323190. Bea S, Salaverria 1, Armengol L, Pinyol M, Fernandez V, HartmannEM, Jares P, Amador V, HernandezL, NavarroA, Ott G , RosenwaldA, Estivill X, CampoE (2008):Uniparentaldisomies, homozygous deletions, amplifications and target genes in mantle cell lymphoma revealed by integrativehigh-resolution whole genome profilling. Blood Epub ahead of print. BednarekAK, L d i n KJ, Daniel RL, Liao Q, HawkinsKA, Aldaz CM (2000):WWOX, a novel WW domain-containing protein mapping to human chromosome 16q23.3-24. I , a region frequently affected in breast cancer. Cancer Res 60:2140-2145. Bentz M, Huck K, du Manoir S, Joos S, Werner CA, Fischer K, Dohner H, Lichter P (1995): Comparativegenomic hybridization in chronic B-cell leukemias shows a high incidence of chromosomalgains and losses. Blood 85:3610-3618. BentzM,BarthTF,BriiderleinS, BockD, SchwererMJ,BaudisM, JoosS,ViardotA,FellerAC,MiillerHermelinkHK, LichterP, DijhnerH, Moller P (200 I): Gainof chromosomearm9p is characteristic of primarymediastinal B-cell lymphoma (MBL): comprehensivemolecularcytogenetic analysis and presentationof a novel MBL cell line. Genes ChromosomesCancer 30393401. Berger R, Bernheim A, Weh HJ, FlandrinG, Daniel MT, Brouet JC, Colbert N (1979): A new translocationin Burkitt’stumor cells. Hum Genet 53:l 11-112. Bergsagel PL, Kuehl WM (200 I): Chromosome translocations in multiple myeloma. Oncogene 20561 1-5622. Bergsagel PL, KuehlWM (2005):Molecularpathogenesisanda consequentclassificationof multiple myeloma. J Clin Oncol23:6333-6338. Bergsagel PL, Chesi M, Nardini E, Brents LA, Kirby SL, Kuehl WM (1996): Promiscuous translocationsinto immunoglobulinheavy chain switch regions in multiple myeloma. Proc Natl Acad Sci USA 93: 13931-13936. Bergsagel PL, Nardini E, Brents L, Chesi M, Kuehl WM (1997):IgH translocationsin multiple myeloma: a nearly universal event that rarely involves c-myc. Curr Top Microbiol lmmunol 224:283-287. Bergsagel PL, Kuehl WM, Zhan F, Sawyer I, Barlogie B, Shaughnessy J Jr (2005): Cyclin D dysregulation:an early and unifying pathogenicevent in multiple myeloma. Blood IO6:296-303.

348

MATURE 8- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

BertrandP, BastardC, MaingonnatC, JardinF, MaisonneuveC, Courel MN, RuminyP, PicquenotJM, Tilly H (2007): Mapping of MYC breakpointsin 8q24 rearrangementsinvolving non-immunoglobulin partnersin B a l l lymphomas. Leukemia 2 1 5 15-523. Biagi JJ,SeymourJF(2002): Insightsinto the molecular pathogenesisof follicularlymphomaarising from analysis of geographic variation.Blood 99:42654275. Boerma EG. Siebert R, Kluin PM, Baudis M (2008): Translocationsinvolving 8q24 in Burkitt lymphoma and other malignant lymphomas: a historical review of cytogenetics in the light of todays knowledge. Leukemia Epub ahead of print. Boersma-VreugdenhilGR, KuipersJ, Van StralenE, PeetersT, Michaux L, HagemeijerA, Pearson PL, Clevers HC, Bast BJ (2004): The recurrent translocation t( 14;20)(q32;q12) in multiple myeloma results in aberrantexpression of MAFB: a molecular and genetic analysis of the chromosomal breakpoint.Br J Haematol I26:355-363. Bosga-BouwerAG, van Imhoff GW, BoonstraR, van derVeen A, HaralambievaE, van den Berg A, de JongB, KrauseV, PalmerMC,CouplandR, KluinPM, vanden Berg E, PoppemaS (2003): Follicular lymphoma grade3B includes 3 cytogeneticallydefined subgroupswith primaryt(14;18), 3q27, or othertranslocations:t(14;18) and 3q27 are mutuallyexclusive. Blood l01:1149-1154. Bosga-Bouwer AG, HaralambievaE, Booman M, BoonstraR, van den Berg A, SchuuringE, van den Berg E, Kluin P, Poppema S (2005): BCL6 alternativetranslocationbreakpointcluster region associated with follicular lymphoma grade3B. Genes Chromosomes Cancer 44:301-304. Bosga-BouwerAG, van den Berg A, HaralambievaE, de JongD, BoonstraR, KluinP, van den Berg E, PoppemaS (2006): Molecular,cytogenetic, and ihununophenotypiccharacterizationof follicular lymphomagrade 3B; a separateentity or partof the spectrumof diffuse largeB-cell lymphomaor follicular lymphoma?Hum Pathol37528-533. BottcherS. Ritgen M, Buske S, Gesk S, KlapperW, HosterE, HiddemannW, UnterhaltM, Dreyling M. SiebertR, KnebaM.Pott C, EU MCLMRD Group(2008): Minimalresidualdiseasedetection in mantle cell lymphoma: methods and significance of four-color flow cytometry compared to consensus IGH-polymerase chain reaction at initial staging and for follow-up examinations. Haematologica 9355 1-559. BoulangerE, Agbalika F, Maarek0, Daniel MT. Grollet L, Molina JM, Sigaux F, OksenhendlerE (2001): A clinical, molecularand cytogenetic study of 12 cases of humanherpesvirus8 associated primaryeffusion lymphoma in HJV-infectedpatients.Hematol J 2: 172-179. Boxer LM, Dang CV (2001): Translocations involving c-myc and c-myc function. Oncogene 205595-56 10. Brito-BabapulleV, Pittman S, Melo JV, Pomfret M, Catovsky D (1987): Cytogenetic studies on prolymphocytic leukemia. I. B-cell prolymphocytic leukemia. Hematol Pathol 1 :27-33. Brito-BabapulleV, Ellis J, Matutes E, Oscier D, KhokharT, MacLennan K, 'Catovsky D (1992): Translocation t( 1 1;14)(qI3;q32) in chronic lymphoid disorders. Genes Chromosomes Cancer 5 : 158- 165. Brito-Babapulle V, Gruszka-WestwoodAM, Platt G, Andersen CL, Elnenaei MO, Matutes E, WotberspoonAC. Weston-SmithSG, Catovsky D (2002): Translocationt(2;7)(p12;q21-22) with dysregulation of the CDK6 gene mapping to 7q21-22 in a non-Hodgkin's lymphoma with leukemia. Haematologica 87:357-362. BrousseauM, Leleu X, GerardJ, GastinneT, GodonA, Genevieve F, Dib M, Lai JL,FaconT,Zandecki M, Intergroupe Francophone du MyClome (2007): Hyperdiploidy is a common finding in monoclonal gammopathyof undeterminedsignificance and monosomy 13 is restrictedto these hyperdiploidpatients. Clin Cancer Res 13:6026-603 1. BuchonnetG, LenainP, RuminyP, LepretreS, StamatoullasA, ParmentierF, JardinF, Duval C, Tilly H, BastardC (2000): Characterisationof BCL2-JHrearrangementsin follicularlymphoma:PCR detection of 3' BCL2 breakpointsand evidence of a new cluster. Leukemia 14: 1563-1 569.

REFERENCES

349

BuchonnetG, JardinF, Jean N, BertrandP, ParmentierF, Tison S, LepretreS, ContentinN, LenainP, Stamatoullas-BastardA, Tilly H, BastardC (2002): Distributionof BCL2 breakpointsin follicular lymphoma and correlationwith clinical features: specific subtypes or same disease? Leukemia 16: 1852-1856. BuhmannR, KurzederC, RehklauJ, WesthausD, Bursch S, HiddemannW, HaferlachT, Hallek M, Schoch C (2002): CD40L stimulationenhancestheabilityof conventionalmetaphasecytogenetics to detect chromosomeaberrationsin B-cell chroniclymphocytic leukaemiacells. Br J Haematol 118:968-975. Busslinger M, Klix N, Pfeffer P, GraningerPG, Kozmik Z (1 996): Deregulation of PAX-5 by translocationof the Emuenhancerof the IgH locus adjacentto two alternativePAX-5 promotersin a diffuse large-cell lymphoma. Proc Natl Acad Sci USA 93:6129-6 134. Butler MP, Iida S, Capello D, Rossi D, Rao PH, NallasivamP, Louie DC,ChagantiS, Au T, Gascoyne RD, GaidanoG,ChagantiRS, Dalla-FaveraR (2002):Alternativetranslocationbreakpointcluster region 5’ to BCL-6 in B-cell non-Hodgkin’slymphoma.Cancer Res 62:4089-4094. CaballeroD, Garcia-MarcoJA, MartinoR, Mateos V, RiberaJM,S a d J, Le6n A, Sanz G, de la Serna J, CabreraR, Gonzalez M. SierraJ, San Miguel J (2005): Allogeneic transplantwith reduced intensity conditioningregimens may overcome the poorprognosis of B-cell chronic lymphocytic leukemia with unmutatedimmunoglobulinvariable heavy-chain gene and chromosomal abnormalities ( 1 Iq- and 17p-). Clin Cancer Res 1 1:7757-7763. CabannesE, Khan G, Aillet F, JarrettRF, Hay UT (1 999): Mutationsin the IkBa gene in Hodgkin’s disease suggest a tumoursuppressorrole for IkappaBalpha.Oncogene 18:3063-3070. CalasanzMJ,CigudosaJC,OderoMD, FerreiraC, ArdanazMT, FraileA, CarrascoJL,Sol6 F, Cuesta B, Gull6n A (1997a): Cytogenetic analysis of 280 patients with multiple myeloma and related disorders:primarybreakpointsandclinical correlations.Genes Chromosomes Cancer 18%-93. CalasanzMJ,CigudosaJC, OderoMD, Garcia-FoncillasJ, MarinJ, ArdanazMT, Rocha E, Gull6n A ( 1997b): Hypodiploidyand 22q I 1 rearrangements at diagnosis areassociatedwith poor prognosis in patients with multiple myeloma. Br J Haemato/98:418-425. Calin GA, DumitruCD, ShimizuM,Bichi R, ZupoS, Noch E, Aldler H, RattanS, KeatingM, Rai K, Rassenti L, Kipps T, Negrini M, Bullrich F, Croce CM (2002): Frequentdeletions and downregulationof micro- RNA genes miR15 and miRI6 at 13q14 in chronic lymphocytic leukemia. Proc Natl Acad Sci USA 99: 15524-15529. CallananMB, Le Baccon P, Mossuz P, Duley S, BastardC, HamoudiR, Dyer u1,KlobeckG, Rimokh R, Sotto JJ, Leroux D (2000):The IgG Fc receptor,FcgammaRIIB,is a targetfor deregulationby chromosomaltranslocationin malignant lymphoma. Proc Natl Acad Sci USA 97:309-314. Callet-BauchuE, Baseggio L, Felman P, Traverse-GlehenA, BergerF, Morel D, Gazzo S, Poncet C, ThieblemontC, CoiffierB, MagaudJP, Salles G (2005): Cytogeneticanalysisdelineatesa spectrum of chromosomalchanges thatcan distinguish non-MALTmarginalzone B-cell lymphomasamong matureB-cell entities: a description of 103 cases. Leukemia 19:181&1823. Carbone A (2003):Emerging pathways in the development of AIDS-related lymphomas. Lancet Oncol422-29. Chang H, Qi C, Yi QL, Reece D, StewartAK (2005a): p53 Gene deletion detectedby fluorescencein situ hybridizationis an adverse prognostic factorfor patients with multiple myeloma following autologous stem cell transplantation.Blood 105:358-360. Chang H, Qi XU, Samiee S, Yi QL, Chen C, Trudel S, Mikhael J, Reece D, Stewart AK (2005b): Genetic risk identifies multiple myeloma patients who do not benefit from autologous stem cell transplantation.Bone Marrow Transplanl 36793-796. Chen W, Iida S, Louie DC, Dalla-FaveraR, ChagantiRS (1998): Heterologous promotersfused to BCL6by chromosomaltranslocationsaffecting band3q27 causeits deregulatedexpressionduring B-cell differentiation.Blood 91:603-607.

350

MATURE B- AND T-CELL NEOPLASMS AND HODGKINLYMPHOMA

Chesi M, NardiniE, Lim RS, Smith KD, Kuehl WM, Bergsagel PL ( 1998a):Thet(4;14) translocation in myelomadysregulatesbothFGFR3anda novel gene, MMSET,resultingin IgWMMSEThybrid transcripts.Blood 92:3025-3034. Chesi M, Bergsagel PL, Shonukan00, Martelli ML, Brents LA, Chen T,SchrijckE, Ried T, Kuehl WM (1998b): Frequentdysregulationof the c-maf proto-oncogeneat 16q23 by translocationto an Ig locus in multiple myeloma. Blood 91 4457-4463. ChevallierP, PentherD, Avet-LoiseauH. RobillardN , IfrahN, MahCB, HamidouM, MaisonneuveH, MoreauP, JardelH, HarousseauJL, Bataille R, GarandR (2002): CD38 expression andsecondary 17p deletion are importantprognostic factors in chronic lymphocytic leukaemia. Br J Haematol 116:142-150. ChikatsuN, Kojima H, Suzukawa K, Shinagawa A, Nagasawa T, Ozawa H, YamashitaY, Mori N (2003): ALK +,CD30-, CD20- large B-cell lymphomacontaininganaplasticlymphomakinase (ALK) fused to clathrin heavy chain gene (CLTC).Mod Puthol 165328432. Chng WJ, Van Wier SA, AhmannGJ, WinklerJM, Jalal SM, Bergsagel PL, Chesi M, TrendleMC, Oken MM, Blood E, HendersonK, Santana-DavilaR. Kyle RA, GertzMA, Lacy MQ, Dispenzieri A, GreippPR, Fonseca R (2005): A validated FISH trisomy index demonstratesthe hyperdiploid and nonhyperdiploiddichotomy in MGUS. Blood 106:2 156-2 16 I . Chng WJ, Santana-DbvilaR, Van Wier SA. AhmannGJ, Jalal SM.Bergsagel PL, Chesi M, Trendle MC, JacobusS, Blood E, Oken MM, HendersonK, Kyle RA, GertzMA, Lacy MQ, DispenzieriA, GreippPR, Fonseca R (2006): Prognostic factors for hyperdiploid-myeloma:effects of chromosome 13 deletions and IgH translocations.Leukemia20:807-813. ChristieL, KemohanN, Levison D, Sales M, CunninghamJ, Gillespie K, Batstone P, MeiklejohnD, GoodladJ (2008): C-MYC translocationin t( 14; 18) positive follicularlymphomaat presentation: an adverse prognostic indicator?Lxuk Lymphoma 49470-476. Chuang S S , Liu H, Martin-SuberoJI, Siebert R, Huang WT, Ye H (2007): Pulmonary mucosaassociated lymphoid tissue lymphoma with strong nuclear 9-cell CLLAymphoma10 (BCLIO) expression and novel translocationt( I ;2)(p22;pI2)/immunoglobulinkappachain-BCLLO. J Clin Path01 60~727-728. ChujDT, HammondD, BairdM, Shield L, JacksonR. JarrettRF(2003): Classical Hodgkinlymphoma is associated with frequentgains of 17q. Genes Chromosomes Cancer 38: I 2 6 136. Cigudosa JC, Rao PH, Calasanz MJ, Odero MD, Michaeli J, JhanwarSC, Chaganti RS (1998): Characterizationof nonrandomchromosomalgains and losses in multiple myelomaby comparative genomic hybridization.Blood 9 1 :3007-3010. Cook JR, AguileraN1, Reshmi-SkarjaS, Huang X, Yu Z, Collin SM, AbbondanzoSL, SwerdlowSH (2004): Lackof PAX5 rearrangementsin lymphoplasmacyticlymphomas:reassessingthe reported association with t(9;14). HumPulhol35:447454. Cools J, WlodarskaI, Somers R, Mentens N, PedeutourF, Maes B, De Wolf-PeetersC, Pauwels P, HagemeijerA, MarynenP (2002): Identificationof novel fusion partnersof ALK, the anaplastic lymphoma kinase, in anaplasticlarge-cell lymphoma and inflammatorymyofibroblastictumor. Genes Chromosomes Cancer 34:354-362. CorcoranMM, Mould SJ, OrchardJA, IbbotsonRE, ChapmanRM. Boright AP, Platt C, Tsui LC, SchererSW, Oscier DG (1999): Dysregulationof cyclin dependentkinase6 expressionin splenic marginalzone lymphoma throughchromosome 7q translocations.Oncogene 18:6271-6277. CremerFW,KartalM. Hose D, Bila J, Buck I, Bellos F, RaabMS, BroughM, Moebus A, HagerHD, GoldschmidtH, Moos M, BartramCR, Jauch A (2005): High incidence and intraclonalheterogeneity of chromosome 1 I aberrationsin patientswith newly diagnosedmultiple myeloma detected by multiprobeinterphaseFISH. Cancer Genet Cytogenef I6 1 :1 16-124. Dave SS, WrightG, Tan B, Rosenwald A, Gascoyne RD, Chan WC, FisherRI,Braziel RM, Rimsza LM, Grogan TM, Miller TP, LeBlanc M. Greiner TC, WeisenburgerDD, Lynch JC, Vose J,

REFERENCES

351

ArmitageJO, SmelandEB, Kvaloy S, Holte H, Delabie J, ConnorsJM, LansdorpPM, OuyangQ, ListerTA. Davies AJ, Norton AJ, Muller-HermelinkHK, Ott G, CampoE, MontserratE, Wilson WH, Jaffe ES, Simon R, Yang L, Powell J, Zhao H, Goldschmidt N, Chiorazzi M, Staudt LM (2004): Prediction of survival in follicular lymphoma based on molecular features of tumorinfiltratingimmune cells. N Engl J Med. 351:2159-2169. Dave SS, Fu K, Wright GW, Lam LT, Kluin P, Boerma EJ, Greiner TC, Weisenburger DD, Rosenwald A, OttG, Muller-HermelinkHK, GascoyneRD, Delabie J, Rimsza LM, Braziel RM, GroganTM, CampoE, Jaffe ES, Dave BJ, SangerW, Bast M, Vose JM, ArmitageJO, Connors JM, SmelandEB, Kvaloy S, Holte H, Fisher R1, Miller TP, MontserratE, Wilson WH, Bahl M, Zhao H, Yang L, Powell J, Simon R, Chan WC, StaudtLM, LymphomaLeukemiaMolecular Profiling Project (2006): Molecular diagnosis of Burkitt’s lymphoma. N Engf J Med 354:243 1-2442. Debes-MarunCS, Dewald GW, BryantS, PickenE, Santana-DavilaR, Gonzalez-PazN, WinklerJM, Kyle RA, Gertz MA, Witzig TE, Dispenzieri A, Lacy MQ, RajkumarSV, Lust JA, Greipp PR. Fonseca R (2003):Chromosomeabnormalitiesclusteringandits implicationsfor pathogenesisand prognosis in myeloma. Leukemia 17:427436. de Leeuw RJ, Davies JJ, Rosenwald A, Bebb G, Gascoyne RD, Dyer MJ, Staudt LM, MartinezCliment JA. Lam W L (2004): Comprehensivewhole genome arrayCGH profilingof mantle cell lymphoma model genomes. Hum Mol Genet 13:1827- 1837. Deleeuw RJ, Zettl A, KlinkerE, HaralambievaE, TrottierM, ChariR, Ge Y, Gascoyne RD, ChottA. Miiller-Hermelink HK, Lam WL (2007): Whole-genome analysis and HLA genotyping of enteropathy-typeT-cell lymphoma reveals 2 distinct lymphoma subtypes. Gastroenterology 132:1902-191 I . Dewald GW, Kyle RA, Hicks GA, GreippPR (1985): The clinical significance of cytogenetic studies in 100 patientswith multiple myeloma, plasmacell leukemia, or amyloidosis. Blood66:38&390. Dewald GW, BrockmanSR, PaternosterSF (2004):Molecularcytogenetic studiesfor hematological malignancies. Cancer Treat Res 121:69-I 12. Dewald GW,TherneauT, LarsonD, Lee YK, FinkS, Smoky S, PaternosterS, AdeyinkaA, Ketterling R, Van Dyke DL, Fonseca R, Kyle R (2005): Relationship of patient survival and chromosome anomalies detected in metaphase andor interphase cells at diagnosis of myeloma. Blood 1W3553-3558. Dicker F, SchnittgerS, HaferlachT, KernW, Schoch C (2006): Immunostimulatoryoligonucleotideinducedmetaphasecytogeneticsdetectchromosomalaberrationsin 80%of CLLpatients:a studyof 132CLLcaseswithcorrelationtoFISH, lgVH status,andCD38 expression.Blood 108:3152-3160. Dierlamm J, Pittaluga S, Wlodarska1, Stul M, Thomas J, Boogaerts M, Michaux L, Driessen A, Mecucci C, CassimanJ-J, De Wolf-PeetersC, Van den Berghe H (1996): Marginalzone B-cell lymphomas of different sites share similar cytogenetic and morphologic features. Blood 87:299-307. DierlammJ, WlodarskaI, MichauxL, VermeeschJR, Meeus P, Stul M, Criel A, VerhoefG, ThomasJ, Delannoy A, Louwagie A, Cassiman JJ, Mecucci C, HagemeijerA, Van den Berghe H (1997): FISH identifies differenttypes of duplicationswith 12q13- 15 as the commonly involved segment in B-cell lymphoproliferativemalignancies characterizedby partialtrisomy 12. Genes Chromosomes Cancer 20: 155-166. Dierlamm1, BaensM,WlodarskaI, Stefanova-OuzounovaM, HernandezJM, Hossfeld DK. De WolfPeetersC, HagemeijerA, Van den BergheH, MarynenP (1999): Theapoptosisinhibitorgene API2 and a novel 18q gene, MLT, are recurrentlyrearrangedin the t( 1 1 ;18)(q21;q2I ) associated with mucosa-associated lymphoid tissue lymphomas.Blood 93:3601-3609. Dohner H, Pohl S, Bulgay-Morschel M, StilgenbauerS, Bentz M, Lichter P (1993): Trisomy 12 in chronic lymphoid leukemias: a metaphase and interphase cytogenetic analysis. Leukemia 7516-520.

352

MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

DohnerH. FischerK, Bentz M, HansenK, BennerA, CabotG,Diehl D, Schlenk R, Coy J, Stilgenbauer S,VolkmannM, Galle PR, PoustkaA, HunsteinW, LichterP (1995):p53 gene deletionpredictsfor poor survivaland non-responseto therapywith purineanalogs in chronicB-cell leukemias.Blood 85:1580- 1589. DiihnerH, StilgenbauerS, FischerK, BentzM, LichterP ( 1997a):Cytogeneticandmolecularcytogenetic analysisof B cell chroniclymphocyticleukemia:specificchromosomeaberrationsidentifyprognostic subgroupsof patientsand point to loci of candidategenes. Leukemia I I(S2) 19-24. Dohner H, StilgenbauerS. JamesMR, BennerA, WeilguniT, Bentz M, Fischer K, HunsteinW, Lichter P ( I 997b): 1 1q deletions identify a new subsetof B-cell chronic lymphocytic leukemiacharacterized by extensive nodal involvement and inferior prognosis. Blood 89:2516-2522. Dohner H, StilgenbauerS, Dohner K, Bentz M, LichterP (1999):Chromosomeaberrationsin B-cell chroniclymphocyticleukemia:reassessmentbased on molecularcytogenetic analysis.JMol Med 77:26&281. DohnerH,StilgenbauerS, BennerA, Leupolt E, Krijber A, BullingerL, DohnerK, Bentz M, LichterP (2000): Genomic aberrationsand survival in chronic lymphocytic leukemia. N Engl J Med 343: 1910-1916. DrachJ. SchusterJ, Nowotny H, AngerlerJ, RosenthalF, Fiegl M, RothermundtC, Gsur A, JagerU, Heinz R, Lechner K, Ludwig H, Huber H (1995): Multiple myeloma: high incidence of chromosomal aneuploidy as detected by interphasefluorescence in situ hybridization.Cancer Res 55:3854-3859. DrachJ, AckemannJ. Fritz E, KromerE, SchusterR, GisslingerH, DeSantis M, ZojerN, Fiegl M, RokaS,SchusterJ, Heinz R, LudwigH, HuberH ( I 998):Presenceof a p53gene deletionin patients with multiple myeloma predicts for short survival after conventional-dosechemotherapy.Blood 92302-809. Drexler HG (1992): Recent results on the biology of Hodgkin and Reed-Stemberg cells. I. Biopsy material.Leuk Lymphoma8:283-313. Du MQ (2007): MALT lymphoma:recent advances in aetiology and moleculargenetics. J Clin Exp Hematop4ik31-42. DurigJ, Bug S, Hein-HitpassL, Boes T, Jons T, Martin-SuberoJl, HarderL, Baudis M,DiihrsenU, SiebertR (2007): Combinedsingie nucleotide polymorphism-basedgenomic mappingand global gene expression profiling identities novel chromosomalimbalances, mechanisms and candidate genes importantin the pathogenesis of T-cell prolymphocyticleukemia with inv( 14)(ql lq32). Leukemia 2 I :2153-2 163. Dyer MJ (2003):The pathogeneticrole of oncogenes deregulatedby chromosomaltranslocationin B-cell malignancies. lnt J Hematol77:315-320. Dyer MJ, Lillington DM, BastardC, Tilly H, Lens D, HewardJM, Stranks G.Morilla R, MonradS, Guglielmi P. Muin-Nelemans JC, Hagemeijer A, Young BD, Catovsky D (1996): Concurrent activationof MYC and BCL2 in B cell non-Hodgkinlymphomacell lines by translocationof both oncogenes to the same immunoglobulin heavy chain locus. Leukemia10:1198-1208. Dyomin VG, Rao PH, Dalla-Favera R, Chaganti RS (1997): BCL8, a novel gene involved in translocationsaffectingband 15q1 1-13 in diffuse large-cell lymphoma. ProcNatl AcadSci USA 94:5728-5732. Dyomin VG, PalanisamyN, Lloyd KO,Dyomina K, JhanwarSC, HouldsworthJ, ChagantiRS (2000): MUCI is activatedin a B-cell lymphomaby the t( 1 ;14)(q21;q32)translocationand is rearranged and amplified in B-cell lymphoma subsets. Blood 95:266&267 I. Einerson RR, Law ME, Blair HE, Kurtin PJ, McClure RF, Ketterling FW,Flynn HC, Dogan A, RemsteinED (2006): Novel FISH probesdesigned to detect IGK-MYCand IGL-MYCrearrangements in B-cell lineage malignancy identify a new breakpointcluster region designated BVR2. Leukemia20:1790-1799.

REFERENCES

353

EmmerichF, MeiserM, HummelM, Demel G, Foss HD, JundtF, MathasS, KrappmannD, Scheidereit C, Stein H, Dorken B (1999): Overexpressionof I kappaB alphawithout inhibitionof NF-kappaB activity and mutationsin the I kappaB alpha gene in Reed-Stemberg cells. Hood 94:3129-3 134. Espinet B, Salido M, Pujol RM, Florensa L, GallardoF, Domingo A, Servitje0, EstrachT, GarciaMuretP, WoessnerS, SerranoS, Sol6 F (2004): Genetic characterizationof SCzary’ssyndromeby conventional cytogenetics and cross-species color banding fluorescent in situ hybridization. Haematologica 89: 165- 173. Fabris S, Storlazzi CT, Baldini L, Nobili L, Lombardi L, Maiolo AT, Rocchi M, Neri A (2003): Heterogeneous pattern of chromosomal breakpoints involving the MYC locus in multiple myeloma. Genes Chromosomes Cancer 37:261-269. Falzetti D, Crescenzi B, Matteuci C, Falini B, Martelli MF, Van Den Berghe H, Mecucci C (1999): Genomic instabilityand recurrentbreakpointsaremain cytogenetic findingsin Hodgkin’sdisease. Haematologica 84:298-305. Fassas AB, SpencerT, Sawyer J, ZangariM, Lee CK, Anaissie E, Muwalla F, MorrisC, Barlogie B, Tricot G (2002): Both hypodiploidy and deletion of chromosome 13 independentlyconfer poor prognosis in multiple myeloma. Br J Haematol 118: 1041-1047. FentonJA, PrattG, Rothwell DG, RawstronAC, MorganGJ(2004):Translocationt(1 I ;14) in multiple myeloma: analysis of translocationbreakpointson der(l1) and der(14) chromosomes suggests complex molecular mechanismsof recombination.Genes Chromosomes Cancer 39: 15 1-155. FentonJA, SchuuringE, BarransSL, BanhamAH, Rollinson SJ, MorganGJ,JackAS, van KriekenJH, Kluin PM (2006): t(3;14)(p14;q32)results in aberrantexpression of FOXPl in a case of diffuse large B-cell lymphoma. Genes Chromosomes Cancer 45: 164-168. Fink SR, Smoley SA, Stocker0 KJ,PaternosterSF, ThorlandEC, Van Dyke DL, ShanafeltTD, Zent CS, Call TG, Kay NE, Dewald GW (2006): Loss of TP53 is due to rearrangementsinvolving chromosome region 17p10-p 12 in chronic lymphocytic leukemia. Cancer Genet Cytogenet 167:177-1 8 1. Fischer TC, Gellrich S, Muche JM, SherevT, AudringH, Neitzel H, WaldenP, Steny W, Tonnies H (2004): Genomic aberrationsand survival in cutaneous T cell lymphomas. J Invest Dermatol 122:579-586. Flactif M, Zandecki M, Lai’ JL, Bernardi F, Obein V, Bauters F, Facon T (1995): Interphase fluorescence in silu hybridization(FISH) as a powerful tool for the detection of aneuploidy in multiple myeloma. Leukemia 9:2 109-2 1 14. Fonseca R, Hoyer JD, Aguayo P, Jalal SM, Ahmann GJ, RajkumarSV, Witzig TE, Lacy MQ, Dispenzieri A, Gertz MA, Kyle RA, GreippPR (1999): Clinical significance of the translocation (1 1 ;14)(q13;q32)in multiple myeloma. k u k Lymphoma 35599405. Fonseca R, Oken MM, GreippPR, EasternCooperativeOncology Group Myeloma Group (2001): The t(4;14)(p16.3;q32) is strongly associated with chromosome 13 abnormalities in both multiple myeloma and monoclonal gammopathy of undetermined significance. Blood 98:127 1 - 1272. FonsecaR, Bailey RJ,AhmannGJ,RajkumarSV, HoyerJD, LustJA, Kyle RA, GertzMA, GreippPR, Dewald GW (2002): Genomic abnormalities in monoclonal gammopathy of Undetermined significance. Blood 100:14 17- 1424. Fonseca R, Blood E, Rue M, HarringtonD, OkenMM, Kyle RA, Dewald GW, Van Ness B, Van Wier SA, HendersonKJ, Bailey RJ, GreippPR (2003): Clinical and biologic implicationsof recurrent genomic aberrationsin myeloma. Bfood 101:4569-4575. FonsecaR, Barlogie B, BatailleR, BastardC, Bergsagel PL, Chesi M, Davies FE, DrachJ, GreippPR, KirschtR,Kuehl WM, HernandezJM,Minvielle S, PilarskiLM, ShaughnessyJD Jr,StewartAK, Avet-Loiseau H (2004): Genetics and cytogenetics of multiple myeloma: a workshop report. Cancer Res 64:1546-1558.

354

MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

FrankeS, WlodarskaI, Maes B, VandenbergheP, Achten R, HagemeijerA. De Wolf-PeetersC (2002): Comparativegenomic hybridizationpatterndistinguishesT-cellhistiocyte-richB-cell lymphoma from nodularlymphocyte predominanceHodgkin's lymphoma. Am J futhol 161:1861-1867. Fu K, WeisenburgerDD, GreinerTC, Dave S, WrightG, Rosenwald A, ChiorazziM, lqbal J, Gesk S, SiebertR, De Jong D, Jaffe ES, Wilson WH, Delabie J, Ott G, Dave BJ, SangerWG, Smith LM, Rimsza L, Braziel RM, Muller-HermelinkHK. Campo E, Gascoyne RD, StaudtLM, Chan WC, LymphomaLeukemiaMolecular ProfilingProject (2005): Cyclin D I-negative mantle cell lymphoma: a clinicopathologic study based on gene expression profiling.Blood l06:43 15-4321. FukuharaS, Rowley JD, VariakojisD, Golomb HM (1 979): Chromosomeabnormalitiesin poorly differentiatedlymphocytic lymphoma. Cancer Re.? 39:3 1 19-3 128. Gabrea A, Bergsagel PL, Chesi M, Shou Y, Kuehl WM (1999): Insertion of excised 1gH switch sequences causes overexpression of cyclin DI in a myeloma tumorcell. MoZ Cell 3: 119-123. GabreaA, Martelli ML, Qi Y. Roschke A, Barlogie B, ShaughnessyJD Jr, Sawyer JR, Kuehl WM (2008): Secondarygenomic rearrangementsinvolving immunoglobulinorMYC loci show similar prevalencesin hyperdiploidand nonhyperdiploidmyeloma tumors.Genes Chromosome.?Cancer 47:573-590. Gascoyne RD, LamantL, Martir-SubemJ1, Lestou VS, HarrisNL,Muller-HennelinkHK, Seymour JF, Campbell W.HorsmanDE, Auvigne I, Espinos E, Siebert R, Delsol G (2003): ALK-positive diffuse largeB-cell lymphomais associated with Clathrin-ALKrearrangements:reportof 6 cases. Blood 102~2568-2573. Gazzo S, Baseggio L, Coignet L, Poncet C, Morel D, Coiffier B, Felman P, BergerF, Salles G, CalletBauchuE (2003): Cytogeneticand moleculardelineationof a regionof chromosome3q commonly gained in marginalzone B-cell lymphoma. Huematologicu 88:3 1-38. Gazzo S, Felman P, Berger F, Salles G, Magaud JP, Callet-BauchuE (2005): Atypical cytogenetic presentationof t( 1 1;14) in mantle cell lymphoma.Huemafologica90: 1708-1709. GertzMA, Lacy MQ,Dispenzieri A, GreippPR, L i m w MR, HendersonKJ, Van Wier SA, Ahmann GJ,Fonseca R (2005): Clinical implicationsoft( I 1 ;l4)(q 13;q32),t(4;14)(pl6.3;q32),and - I7pl3 in myeloma patients treatedwith high-dose therapy.Blood 106:2837-2840. Gesk S , Marth-SuberoJl, HarderL, LuhmannB, SchlegelbergerB, CalasanzMJ,GroteW. SiebertR (2003): Molecularcytogenetic detectionof chromosomalbreakpointsin T-cell receptorgene loci. Leukemia 17:138-745. Gesk S, GascoyneRD, SchnitzerB, Bakshi N,JanssenD, KlapperW, Martin-SuberoJ1, ParwareschR, SiebertR (2005): ALK-positivediffuse largeB-cell lymphomawith ALK-Clathrinfusion belongs to the spectrumof pediatric lymphomas. Leukemia 19:1839- 1840. Gesk S, Klapper W, Madn-SuberoJI, Nagel I, HarderL, Fu K, Bernd HW, WeisenburgerDD, ParwareschR, Siebert R (2006): A chromosomal translocation in cyclin' D1 -negative/cyclin D2-positive mantle cell lymphoma fuses the CCND2 gene to the IGK locus. Blood 108: 1109-1110.

Giefing M. ArnemannJ, Martin-SuberoJ1, Nielander I, Bug S, HartmannS, Arnold N, Tiacci E, Frank M, Hansmann ML, Kuppers R, Siebert R (2008): Identification of candidate tumour suppressorgene loci for Hodgkin and Reed-Stembergcells by characterisationof homozygous deletions in classical Hodgkin lymphomacell lines. Br J Haemafol l42:9 16-924. Gilles F, Goy A, RemacheY,ShueP, Zelenetz AD (2000): MUC 1 dysregulationas the consequenceof a t( I ;I4)(q21:q32) translocationin an extranodallymphoma. BIood 95:2930-2936. Greiner TC, Dasgupta C, Ho VV, WeisenburgerDD, Smith LM, Lynch JC, Vose JM, Fu K, Armitage JO, Braziel RM, Campo E, Delabie J, Gascoyne RD, Jaffe ES. Muller-Hermelink HK, Ott G, Rosenwald A, StaudtLM, Im MY, KaramanMW, Pike BL, Chan WC, Hacia JG (2006): Mutationand genomic deletion status of ataxiatelangiectasiamutated(ATM) and p53 confer specific gene expression profiles in mantle cell lymphoma. froc Nut/ Acad Sci USA 103:2352-2357.

REFERENCES

355

Grever MR, Lucas DM, Dewald GW, Neuberg DS, Reed JC, Kitada S, Flinn IW,Tallman MS, AppelbaumFR. Larson RA, PaiettaE, Jelinek DF, GribbenJG, Byrd JC (2007): Comprehensive assessment of genetic and molecular features predicting outcome in patients with chronic lymphocytic leukemia: results from the US IntergroupPhase III Trial E2997. J Clin Oncol 25799-804. Gruszka-WestwoodAM, Hamoudi R, OsborneL, MatutesE, Catovsky D (2003): Deletion mapping on the long arm of chromosome 7 in splenic lymphoma with villous lymphocytes. Genes Chromosomes Cancer 3 6 5 7 4 9 . (Erratumin Genes Chromosomes Cancer, 2004, 39: 170) GutitrrezNC, GarciaJL,HernandezJM,LumbrerasE, CastellanosM, Rasillo A, MateoG ,Hernindez JM, PtrezS, OrfaoA, San Miguel JF(2004): Prognosticandbiologic significanceof chromosomal imbalances assessed by comparative genomic hybridization in multiple myeloma. Blood 104~2661-2666. Guti6rrez NC, CastellanosMV, MartinML, Mateos MV, HernindezJM, FernindezM, CarreraD, Rosifiol L, RiberaJM, OjangurenJM, PalomeraL, GardellaS, Escoda L, Hernindez-BoludaJC, Bello JL, de la Rubia J, LahuertaJJ. San Miguel JF, G E W E T H E M ASpanish Group (2007): Prognosticand biological implicationsof genetic abnormalitiesin multiplemyeloma undergoing autologous stem cell transplantation:t(4;14) is the most relevant adverse prognostic factor, whereasRB deletion as a uniqueabnormalityis not associated with adverseprognosis. Leukemia 2 I :143-150. HaferlachC, Dicker F, SchnittgerS, KernW, HaferlachT (2007): Comprehensivegenetic characterizationof CLL:a studyon 506 cases analysedwith chromosomebandinganalysis,interphaseFISH, IgV(H) status and immunophenotyping.Leukemia 21 :2442-245 1. HahtolaS, BurghartE, JeskanenL, KarenkoL, Abdel-RahmanWM, PolzerB, KajantiM, Peltomiki P, Pettersson T, Klein CA, Ranki A (2008): Clinicopathological characterizationand genomic aberrationsin subcutaneouspanniculitis-likeT-cell lymphoma.J Invest Dermatol128:2304-2309. HallekM, Bergsagel PL, AndersonKC (1998): Multiplemyeloma:increasingevidence for a multistep transformationprocess. Blood 91:3-2 1. Hallek M, Cheson BD, Catovsky D, Caligaris-CappioF, Dighiero G, Dohner H,Hillmen P, Keating MJ, MontserratE, Rai KR, KippsTJ (2008): Guidelinesfor the diagnosis and treatmentof chronic 1ymphocytic leukemia: a report from the International Workshop on Chronic Lymphocytic Leukemia (IWCLL) updating the National Cancer Institute-WorkingGroup (NCI-WG) 1996 guidelines. Blood 1 1 1:54465456. HallermannC, Kaune KM, Gesk S, Martin-SuberoJI, Gunawan B, Griesinger F, Vermeer MH, Santucci M, Pimpinelli N, Willemze R, Siebert R, Neumann C (2004a): Molecularcytogenetic analysis of chromosomalbreakpointsin the lGH, MYC, BCLQ and MALT1 gene loci in primary cutaneous B-cell lymphomas. J Invest Dermatol 123:213-2 19. HallermannC, KauneKM, SiebertR. VermeerMH, TensenCP,Willemze R, GunawanB, BertschHP, NeumannC (2004b): Chromosomalaberrationpatternsdifferin subtypesof primarycutaneousB cell lymphomas. J Invest Dermatol 122:1495-1 502. HanamuraI, Iida S, Akano Y,Hayami Y, Kato M, Miura K, HaradaS, Banno S, WakitaA, Kiyoi H, Naoe T, Shimizu S, Sonta SI, Nitta M, TaniwakiM, Ueda R (2001): Ectopic expressionof MAFB gene in human myeloma cells carrying (14;20)(q32;qlI) chromosomal translocations. Jpn J Cancer Res 92:638-644. HanamuraI, StewartJP,HuangY, ZhanF, SantraM, SawyerJR,Hollmig K, ZangarriM, Pineda-Roman M, van Rhee F, Cavallo F, BuringtonB, CrowleyJ, TricotG, BarlogieB, ShaughnessyJDJr(2006): Frequentgain of chromosomeband lq21 in plasma-celldyscrasiasdetectedby fluorescencein situ hybridization:incidenceincreasesfromMGUS to relapsedmyeloma andis relatedto prognosisand disease progressionfollowing tandem stem-cell transplantation.Blood 108:1724-1 732. Hao S, SangerW, Onciu M, Lai R, SchletteEJ, MedeirosLJ (2002): Mantlecell lymphomawith 8q24 chromosomalabnormalities:areportof 5 cases with blastoid features.ModPathol15: 1266-1272.

356

MATURE B-AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

Hams NL, Jaffe ES, Stein H, BanksPM, ChanJK,ClearyML, Delsol G, De Wolf-PeetersC, Falini B, Gatter KC ( 1994): A revised European-American classification of lymphoid neoplasms: a proposal from the InternationalLymphomaStudy Group. Blood 84: 1361-1 392. HarrisNL, JaffeES, Diebold J, FlandrinG. Muller-HermelinkHK, VardimanJ, ListerTA, Bloomfield CD (1 999): WorldHealth Organizationclassification of neoplastic diseases of the hematopoietic andlymphoid tissues: reportof the Clinical Advisory CommitteeMeeting, Airlie House, Virginia, November 1997. J Clin Oncol17:3835-3849. HamsNL, Jaffe ES, Diebold J, FlandrinG, Muller-HermelinkHK, VardimanJ, ListerTA, Bloomfield CD (2000): The WorldHealthOrganizationclassificationof hematological malignanciesreportof the Clinical Advisory CommitteeMeeting, Airlie House, Virginia,November 1997. Mod Puthol 13: 193-207. HarrisonCJ, Mazzullo H, Ross FM, Cheung KL, (4errardG, HarewoodL,Mehta A, LachmannHJ, HawkinsPN, OrchardKH (2002): Translocationsof 34q32 and deletions of 13q14 arecommon chromosomal abnormalitiesin systemic amyloidosis. Br J Haematol 1 17:427-435. HartmannS, Martin-SuheroJl, Gesk S, Husken J, Giefing M, Nagel I. RiemkeJ, Chott A, Klapper W, ParrensM, Merlio JP,KiippersR, BrauningerA, SiebertR, HansmannML (2008): Detection of genomic imbalances in microdissected Hodgkin and Reed-Sternberg cells of classical Hodgkin’s lymphoma by array-basedcomparativegenomic hybridization.Haematologicu93: 1318-1 326. HatzivassiliouG, Miller I, TakizawaJ, PalanisamyN, Rao PH, Iida S, TagawaS, TaniwakiM, RussoJ, Neri A, CattorettiG, Clynes R, MendelsohnC, ChagantiRS, Dalla-FaveraR (2001): IRTAl and IRTA2, novel immunoglobulin superfamily receptors expressed in B cells and involved in chromosome lq2 I abnormalitiesin B cell malignancy.Immunity 14277-289. He L, ThomsonJM, HemannMT,Hernando-MongeE, Mu D, GoodsonS. PowersS,Cordon-CardoC, Lowe SW, HannonGJ, HammondSM (2005): A microRNA polycistron as a potential human oncogene. Nature435828-833. Herens C, LambertF, Quintanilla-MartinezL, Bisig B, Deusings C, de Leva1 L (2008): Cyclin DInegative mantle cell lymphoma with cryptic t( 12;14)(pl3;q32) and cyclin D2 overexpression. Blood 1 I 1 :1745- 1746. Herholz H, Kern W, SchnittgerS, Haferlach T, Dicker F, HaferlachC (2007): Translocationsas a mechanismfor homozygous deletion of 13q14 and loss of the ATM gene in a patientwith B-cell chronic lymphocytic leukemia. CancerGenet Cytogenet 174:57-60. HernandezL, Pinyol M, HernindezS, BeB S, Pulford K, Rosenwald A, Lamant L, Falini B, Ott G, Mason DY, Delsol G, Campo E (1999): TRK-fused gene (TFG) is a new partnerof ALK in anaplasticlarge cell lymphomaproducing two structurallydifferent TFG-ALK translocations. Blood 94:3265-3268. HernindezJM, GarciaJL, GutiCrrezNC, Mollejo M, Martinez-ClimentJA, FloresT, Gonzilez MB, p i n s MA, San Miguel J F (2001): Novel genomic imbalances in B-cell splenic marginalzone lymphomas revealed by comparative genomic hybridization and cytogenetics. Am J Puthol 158:1843-1850. Higgins MJ, Fonseca R (2005): Genetics of multiple myeloma. Besl Pract Res Clin Huematol 18:525-536. Hillengass J, ZechmannCM, Nadler A, Hose D, CremerFW, JauchA, Heiss C, Benner A, Ho AD, BartramCR, Kauczor HU. Delorme S, Goldschmidt H, Moehler TM (2008): Gain of lq21 and distinct adverse cytogenetic abnormalitiescorrelatewith increased microcirculationin multiple myeloma. Int J Cancer 122:2871-2875. HoglundM, Sehn L, ConnorsJM, Gascoyne RD, SiebertR, Sill T, MitelmanF, HorsmanDE (2004): Identificationof cytogenetic subgroupsand karyotypicpathwaysof clonal evolution in follicular lymphomas. Genes ChromosomesCancer39: 195-204.

REFERENCES

357

HonmaK, Tsuzuki S, NakagawaM, KamanS, Aizawa Y, Kim WS, Kim YD, KOYH, Set0 M (2008): TNFAIP3 is the targetgene of chromosome band 6q23.3324.1 loss in ocular adnexal marginal zone 0 cell lymphoma. Genes Chromosomes Cancer 47: 1-7. HorsmanD, GascoyneR, Klasa R, CouplandR (1992):t( 1 1 ;18)(q2 I ;q21.1): a recurringtranslocation in lymphomas of mucosa-associated lymphoid tissue (MALT)? Genes Chromosomes Cancer 4:183-187. HorsmanDE. ConnorsJM, PantzarT, Gascoyne RD (2001): Analysis of secondary chromosomal alterations in 165 cases of follicular lymphoma with t(14;lS). Genes Chromosomes Cancer 30~375-382. HorsmanDE, Okamoto1, Ludkovski0, Le N, HarderL, Gesk S, SiebertR, ChhanabhaiM, Sehn L, ConnorsJM, Gascoyne RD (2003):Follicularlymphomalacking the t( 14;18)(q32;q21):identification of two disease subtypes. Br J Haematol 120:424-433. Hummef M, Bentink S, Berger H, KlapperW, Wessendorf S, BarthTF, Bernd HW, Cogliatti SB, DierlammJ,FellerAC, HansmannML, HaralambievaE, HarderL, HasencleverD, KuhnM, Lenze D, LichterP, Martin-SuberoJI, Moller P, Muller-HermelinkHK, Ott G, ParwareschRh4, Pott C, RosenwaldA, Rosolowski M, SchwaenenC, StiirzenhofeckerB, SzczepanowskiM, TrautmannH, Wacker HH, Spang R, Loeffler M, TriimperL, Stein H, Siebert R, Molecular Mechanisms in MalignantLymphomasNetworkProjectof the Deutsche Krebshilfe(2006):A biologic definition of Burkitt’slymphomafromtranscriptionaland genomic profiling.N Engl JMed 354:2419-2430. Iida S, Rao PH, Nallasivam P,Hibshoosh H, Butler M, Louie DC,Dyomin V, Ohno H, ChagantiRS, Dalla-Favera R (1 996): The t(9;14)(pl3;q32)chromosomal translocationassociated with lymphoplasmacytoidlymphoma involves the PAX-5 gene. Blood 88:411@4117. Iqbal J, Sanger WG, HorsmanDE, Rosenwald A, Pickering DL, Dave B, Dave S, Xiao L, Cao K, Zhu Q, Sherman S, Hans CP. WeisenburgerDD, GreinerTC, Gascoyne RD, Ott G, MullerHermelinkHK, Delabie J, Braziel RM, Jaffe Es,Camp0 E, Lynch JC, Connors JM, Vose JM, Armitage JO, Grogan TM, StaudtLM, Chan WC (2004): BCL2 translocationdefines a unique tumorsubset within the germinal center B-cell-like diffuse large B-cell lymphoma.Am J Pathol 165:1 59-1 66. Iqbal J, GreinerTC, Patel K, Dave BJ, Smith L, Ji J, Wright G, SangerWG, Pickering DL, Jain S, HorsmanDE, Shen Y,Fu K. WeisenburgerDD, HansCP, Camp0E, Gascoyne RD, RosenwaldA, Jaffe ES, Delabie J, Rimsza L, OttG, Miiller-HermelinkHK, ConnorsJM, Vose JM,McKeithanT, Staudt LM, Chan WC, Leukemia4,ymphoma Molecular Profiling Project (2007): Distinctive patternsof BCL6molecularalterationsandtheirfunctionalconsequencesin differentsubgroupsof diffuse large B-cell lymphoma. Leukemia 21 :2332-2343. Isaacson PG,Du MQ (2003): Gastric lymphomas: genetics and resistanceto H. pylori eradication. Verh Dtsch Ges Pathol87:1 1 6 122. Isaacson PG, Du MQ (2004): MALT lymphoma:from morphology to molecules. Nut Rev Cancer 4:644-653. Isaacson PG, Du MQ (2005): Gastrointestinal lymphoma: where morphology meets molecular biology. J Pathol205:255-274. ItoyamaT,ChagantiRS, YamadaY,TsukasakiK, Atogami S, NakamuraH, TomonagaM, OhshimaK, Kikuchi M. SadamoriN (2001): Cytogenetic analysis and clinical significance in adult T-cell, leukemiallymphoma:a study of 50 cases from the humanT-cell leukemia virus type- I endemic area, Nagasaki. Blood 97:3612-3620. Jaffe ES, Harris NL, Stein H, Vardiman JW,editors (2001): The World Health Organization Classification of Tumours: Pathology & Genetics. Tumours of Haematopoietic and Lymphoid Tissues. Lyon: lACR F’ress. Janssen JW,VaandragerJW, Heuser T, Jauch A, Kluin PM, Geelen E, Bergsagel PL, Kuehl WM, DrexlerHG, OtsukiT, BartramCR, SchuuringE (2000):Concurrentactivationof a novel putative

358

MATURE 8- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

transforminggene, myeov, and cyclin D1 in a subset of multiple myeloma cell lines with t( 1 I ;14) (413;q32). Blood 95:269 1-2698. JardinF, GaulardP, BuchonnetG. ContentinN, LeprhtreS, Lenain P, StamatoullasA, PicquenotJM, Duval C, ParmentierF, Tilly H, BastardC (2002): Follicularlymphomawithoutt(14;18) and with BCL-6 rearrangement:a lymphoma subtype with distinct pathological, molecular and clinical characteristics.Leukemia 16:2309-23 17. JardinF, Ruminy P, Bastard C, TiIly H (2007): The BCL6 proto-oncogene: a leading role during germinal center developmentand lymphomagenesis.Pathol Biol (Paris) 55:73-83. JaresP, ColomerD, CampoE (2007): Genetic and molecularpathogenesisof mantlecell lymphoma: perspectives for new targetedtherapeutics.Nut Rev Cancer7:750-762. Johansson B, Mertens F, Mitelman F (1995): Cytogenetic evolution patterns in non-Hodgkin’s lymphoma.Blood 86:3905-39 14. JonveauxP, Daniel MT, MartelV, Maarek0,BergerR (1996): Isochromosome7q and trisomy 8 are consistent primary, non-random chromosomal abnormalitiesassociated with hepatosplenic T gammddeltalymphoma. Leukemia 10:1453-1455. Joos S, Falk MH, LichterP, HaluskaFG, Henglein B, Lenoir GM, BornkammGW (1992a): Variable breakpointsin Burkittlymphomacells with chromosomalt(8; 14) translocationseparatec-myc and the IgH locus up to several hundredkb. Hum Mol Genet 1:625-632. Joos S, Haluska FG, Falk MH, Henglein B, Hameister H, Croce CM. Bomkamm GW (1992b): Mapping chromosomal breakpoints of Burkitt’s t(8;14) translocations far upstreamof c-myc. CancerRes 52:65414552. Joos S, Kupper M, Oh1 S, von Bonin F, MechtersheimerG, Bentz M, Marynen P, Moller P, PfreundschuhM, TrumperL, LichterP (2000): Genomic imbalancesincluding amplificationof the tyrosine kinase gene JAK2 in CD30+ Hodgkin cells. CancerRes 60549-552. Joos S, Menz CK, Wrobel G. Siebert R, Gesk S, Oh1 S, MechtersheimerG, TriimperL, Moller P, Lichter P, Barth TF (2002): Classical Hodgkin lymphoma is characterizedby recurrentcopy numbergains of the short arm of chromosome 2. Blood 99:1381-1 387. Joos S, Granzow M, Holtgreve-GrezH, SiebertR, HarderL, Martin-SuberoJI, Wolf J, Adamowicz M, Barth TF, Lichter P, Jauch A (2003): Hodgkin’s lymphoma cell lines are characterizedby frequent aberrationson chromosomes 2p and 9p including REL and JAK2. fnt J Cancer 103:489495. Juge-MorineauN, Mellerin MP, FrancoisS , RappMJ, HarousseauJL,Amiot M, Bataille R (1995): High incidence of deletions but infrequent inactivation of the retinoblastomagene in human myeloma cells. Br J Haemalol91 :664-667. Juliusson G, Oscier DG, Fitchett M, Ross FM, Stockdill G. Mackie MJ, ParkerAC, Castoldi GL, Gunm A, KnuutilaS,et al. (1990): Prognosticsubgroupsin B-cell chroniclymphocytic leukemia defined by specific chromosomalabnormalities.N Engl J Med 323:720-724. Diehl V,HansmannML, Rajewsky JungnickelB, Staratschek-JoxA, BriuningerA, SpiekerT, Wolf .I, K, KuppersR (2000): Clonaldeleteriousmutationsin the IkappaBalphagene in the malignantcells in Hodgkin’s lymphoma.J Exp Med 191:395402. KamadaN, SakuraiM, Miyamoto K, Sanada1, SadamoriN, FukuharaS, Abe S, ShiraishiY, Abe T, KanekoY,ShimoyamaM ( 1992):Chromosomeabnormalitiesin adultT-cell leukemia/lymphoma: a karyotype review committee report.CancerRes 52: 148 1-1493. KanekoY, Maseki N, SakuraiM, TakayamaS, NanbaK, KikuchiM, FrizzeraG (1 988): Characteristic karyotypic pattern in T-cell lymphoproliferativedisorders with reactive “angioimmunoblastic lymphadenopathywith dysproteinemia-type”features. Blood 72:4 13-42 1. Kanungo A, Medeiros LJ, Abruzzo LV, Lin P (2006): Lymphoid neoplasms associated with concurrentt( 14;18) and 8q24k-MYC translocation generally have a poor prognosis. Mod Pathol I9:25-33.

FIGURE 2.1

Examplesof different cytogenetic techniquesapplied to the same case. A supernumeraryring chromosome(arrow)is identifiedby G-banding(a) in a mesenchymaltumorand shown by multicolor FISH (b) to contain sequences from chromosomes 9 (arrowhead)and 12 (arrow). Whole-chromosomepainting(c)of chromosomes9 (red)and I 2 (green)corroboratesthese findings and multicolor chromosome 12 banding with yeast artificial chromosome probes (d) shows that sequencesfromtheMDMZ(yel1ow)andCDK4(violet)genesin 12q14-1Sareamplifiedin the rings. Furtheranalysis by bacterial artificial chromosome arrayCGH (e) defines the boundariesof the CDK4 and MDM2 amplified segments; the y-axis correspondsto logz intensity ratios. Images are courtesy of N. Mandahl and M. Heidenblad.

CEN

-

RP11-120K16

(a)

FIPlLl

RPl1-3H20

CHIC2 PDGFRA

-

100 u

WT TEL

RPt l-24OtQ

FIGURE 8.2 FISH detectionof the 4q12 deletion associatedwith the FIF'ILI-PDGFRA fusion. (See te.r~forfull caption.)

FIGURE 10.1 Schematicrepresentation of the mechanismsleading to IGHtranslocationsin B-cell malignancies(based on Willis and Dyer, 2000; Kuppersand Dalla-Favera,2001). (a) IGH locus germlineconfigurationdisplayingvariable( V H )joining , ( J H ) diversity , ( D H )and . constant(C)regions. Switchregions(blackandwhite rectangles)lie upstreamof each constantregionwith the exceptionof C6. E p and Ea enhancersare shown in red. (b) Schematicrepresentation of the VDJ recombination, class switch recombination.and somatichypermutationmechanisms.(c) Formationof IGHtranslocations. Depending on the breakpoint location at 14q32, the IGH locus may deregulateprotooncogenes in both partnerchromosomesthroughthe translocation(elbowed arrows).

FIGURE 14.7 FISHevaluationusingcentromericprobesforchromosomesI , 7, and I7 performed on interphasenuclei, showing (a) monosomy for chromosomes1 and 17 and disomy for chromosome 7, consistent with chromophobetype RCC; and (b) trisomy for chromosomes7 and 17 and disomy for chromosome I. consistentwith papillarytype RCC.

FIGURE 14.1 1 This t( 12;15)(pI3;q26)is a characteristictranslocationin congenitalmesoblastic nephroma.(a)This is a cryptictranslocation;therefore,FISHanalysisusing the EW6 probeat 1 2 ~ 1 3 is necessary to confirm the translocationeitherin (b) metaphasechromosomesor in (c) interphase nuclei (Courtesyof Dr. JonathanFletcher).

FIGURE 14.13 InterphaseFISH-analysisof cells from the urinarytract:(a) Normalhybridization patternshowing disomy for each probe tested; (b) abnormalhybridizationpatterntonsistent with tetrasomyforchromosomes3 and7, trisomy 17, and nullisomy for the 9p2 I probe (i.e., homozygous deletionof the correspondingregion) (Courtesyof Dr. StanaWeremowicz).

FIGURE 183 Detection of double minutes (dmin) and homogeneously staining regions (hsr) in neuroblastoma by fluorescence in situ hybridization, using probes for MYCN (red in a; green in b-d). (See te.rt forfull caption.)

FIGURE 193 A translocation involving chromosomes 1 and 19 in oligodendroglioma. (See textfor fill caption.)

REFERENCES

359

KarenkoL, HahtolaS, Paivinen S, KarhuR. S y j a S, KahkonenM, Nedoszytko B, Kytola S, Zhou Y, Blazevic V, Pesonen M, Nevala H, Nupponen N, Sihto H, Krebs I, Poustka A, Roszkiewicz J, Saksela K, Peterson P, VisakorpiT, Ranki A (2005): PrimarycutaneousT-cell lymphomasshow a deletion or translocation affecting NAV3, the human UNC-53 homologue. Cancer Res 65:8101-8110. KarsanA, GascoyneRD, CouplandRW, ShepherdJD, PhillipsGL, HorsmanDE ( 1993):Combination oft( 14;18) anda Burkitt’stype translocationin B-cell malignancies.Leuk Lymphoma I0:433-441. KatzenbergerT, Ott G, Klein T, Kalla J, Muller-HermelinkHK, Ott MM (2004): Cytogenetic alterationsaffecting BCL6 are predominantlyfound in follicular lymphomas grade 3B with a diffuse large B-cell component.Am J Pathol 165:481-490. KatzenbergerT. Kalla J, Leich E, Stocklein H, HartmannE, Barnickel S, Wcssendorf S, Ott MM, Muller-HermelinkHK, Rosenwald A. Ott G (2008): A distinctive subtype of t( 14;18) negative nodal follicularnon-Hodgkinlymphomacharacterizedby a predominantlydiffuse growth pattern and deletions in the chromosomalregion 1 p36. Blood Epub ahead of print. KaufmannH, KromerE, Nosslinger T, WeltermannA, AckermannJ, Reisner R, BernhartM, DrachJ (2003): Both chromosome I3 abnormalitiesby metaphase cytogenetics and deletion of 13q by interphase FISH only are prognostically relevant in multiple myeloma. Eur J Haematol 7 I :179- 183. Kearney L, Horsley SW (2005): Molecular cytogenetics in haematological malignancy: current technology and futureprospects. Chromosoma 1 14:28&294. KeatsJJ,ReimanT, Maxwell CA, TaylorBJ, LarrattLM, MantMJ, Belch AR, PilarskiLM (2003): In multiple myeloma, t(4; I4)(p16;q32) is an adverse prognostic factor irrespective of FGFR3 expression. Blood I01:1520- 1529. KeatsJJ, Maxwell CA, TaylorBJ, Hendzel MJ,Chesi M, Bergsagel PL, LarrattLM, MantMJ, Reiman T, Belch AR, Pilarski LM (2005): Overexpressionof transcriptsoriginating from the MMSET locus characterizes all t(4;14)(pl6;q32)-positive multiple myeloma patients. Blood 105:4060-4069. KerckaertJP, Deweindt C, Tilly H, Quief S, Lecocq G, BastardC (1993): LAZ3, a novel zinc-finger encoding gene, is disruptedby recurringchromosome3q27 translocationsin human lymphomas. Nut Genel 5166-70. KimmLR, deLeeuwRJ, Savage KJ, RosenwaldA, CampoE, Delabie J. Ott G, Muller-HermelinkHK, Jaffe ES. Rimsza LM, WeisenburgerDD, ChanWC, StaudtLM, ConnorsJM,Gascoyne RD, Lam WL (2007): Frequentoccurrenceof deletions in primarymediastinal B-cell lymphoma. Genes Chromosomes Cancer 46: 1090-1097. Klapper W, Stoecklein H, Zeynalova S, Ott G, Kosari F, Rosenwald A, Loeffler M, TriimperL, Pfreundschuh M, Siebert R; German High-Grade Non-Hodgkin’s Lymphoma Study Group (2008):Structuralaberrationsaffecting the MYC locus indicatea poorprognosis independentof clinical risk factorsin diffuse large B-cell lymphomas treated within randomizedtrials of the German High-Grade Non-Hodgkin’s Lymphoma Study Group (DSHNHL). Leukemia 22: 2226-2229. KnebaM, Eick S, HerbstH, WilligerothS, PottC, Bolz 1, Bergholz M, NeumannC, Stein H, KriegerG ( I99 I): Frequencyand structureoft(14;18) majorbreakpointregions in non-Hodgkin’slymphomas typed according to the Kiel classification: analysis by direct DNA sequencing. Cancer Res 5 1 :3243-3250. Knezevich S, Ludkovski0,Salski C, Lestou V, ChhanabhaiM, Lam W, Klasa R, ConnorsJM, Dyer MJ,GascoyneRD, HorsmanDE (2005): Concurrenttranslocationof BCL2 andMYC with a single immunoglobulin locus in high-gradeB-cell lymphomas. Leukemia I9:659-663. KohlhammerH, SchwaenenC, WessendorfS, HolzmannK, KestlerHA, Kienle D, BarthTF, Moiler P, Ott G, Kalla J, RadlwimmerB, PschererA, StilgenbauerS, DohnerH, LichterP, Bentz M (2004): Genomic DNA-chip hybridization in t( 1 I;14)-positive mantle cell lymphomas shows a high

360

MATURE B-AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

frequency of aberrationsand allows a refined characterizationof consensus regions. Blood 104:795-801. Komatsu H, Yoshida K, Set0 M, Iida S, Aikawa T, Ueda R, Mikuni C (1993): Overexpressionof PRADl in a mantlezone lymphomapatientwith a t( I 1 ;22)(q13;qI 1 ) translocation.Br JHaematol W427-429. KroberA, Seiler T, BennerA, Bullinger L, Bruckle E, LichterP, DohnerH, StilgenbauerS (2002): V (H) mutation status, CD38 expression level, genomic aberrations, and survival in chronic lymphocytic leukemia. Blood 100: 1410-3416. KroberA, BloehdornJ, HafnerS, BuhlerA, Seiler T. Kienle D, WinklerD, BangerterM, Schlenk RF, BennerA, LichterP, Dohner H, StilgenbauerS (2006): Additionalgenetic high-risk featuressuch as I l q deletion, 17p deletion, and V3-21 usage characterizediscordanceof ZAP-70 and VH mutation status in chronic lymphocytic leukemia. J Clin Oncol24:969-975. KrogerN, Schilling G, Einsele H, Liebisch P, Shimoni A, Nagler A, PCrez-SimonJA, San Miguel JF, Kiehl M, FauserA, SchwerdtfegerR, WandtH, Sayer HG, Myint H, KlingemannH, ZabelinaT, Dierlamm J, Hinke A, ZanderAR (2004): Deletion of chromosomeband 13q14 as detected by fluorescencein situ hybridizationis a prognosticfactorin patientswith multiple myelomawho are receiving allogeneic dose-reducedstem cell transplantation.Blood 103:4056-406 1. KrugmannJ, Tzankov A, Dirnhofer S, Fend F, Greil R, Siebert R, Erdel M (2004): Unfavourable prognosisof patientswith trisomy 1 8q21 detectedby fluorescence in situ hybridisationin t( 1 I ;18) negative, surgically resected, gastrointestinalB cell lymphomas.J Clin fathol 57:360-364. Kuehl WM, Bergsagel PL (2002): Multiplemyeloma: evolving genetic events and host interactions. Nat Rev Cancer 2:175-187. KuppersR (2005): Mechanisms of B-cell lymphoma pathogenesis. Nut Rev Cancer 5 2 5 1-262. KuppersR, Dalla-FaveraR (2001): Mechanismsof chromosomaltranslocationsin B cell lymphomas. Oncogene 205580-5594. KuppersR, Klein U, HansmannML, RajewskyK ( 1 999): Cellularorigin of humanB-cell lymphomas. N Engl J Med 341: 1520-1529. KuppersR, Sonoki T, SatterwhiteE, Gesk S, HarderL, Oscier DO, TuckerPW, Dyer MJ, SiebertR (2002): Lack of somatic hypermutationof IG V(H) genes in lymphoid malignancieswith t(2;14) (p 13;q32) translocationinvolving the BCLl 1A gene. Leukemia 16:937-939. Lai'JL,ZandeckiM, MaryJY, BernardiF, IzydorczykV, Flactif M, MorelP, JouetJP,BautersF,Facon T ( I 995): lmproved cytogenetics in multiple myeloma: a study of I5 I patients including 1 17 patients at diagnosis. Blood 85:2490-2497. LamantL, Dastugue N, Pulford K, Delsol G, MariamCB (1999): A new fusion gene TPM3-ALK in anaplasticlarge cell lymphomacreated by a ( 1;2)(q25;p23)translocation.Blood 93:3088-3095. Lecointe N, Meerabux J, EbiharaM, Hill A, Young BD (1999): Molecular analysis of an unstable genomic region at chromosomeband 1 lq23 reveals a disruptionof the gene encodingthe alpha2 subunitof platelet-activatingfactor acetylhydrolase(Pafahla2) in human lymphoma. Oncogene 18~2852-2459. Leich E, HaralambievaE, Zettl A, Chott A, Rudiger T, Holler S, Muller-HermelinkHK, Ott G, Rosenwald A (2007): Tissue microarray-basedscreening for chromosomalbreakpointsaffecting the T-cell receptor gene loci in matureT-cell lymphomas.J Pathol213:99-105. LennertK, Stein H, KaiserlingE (1975): Cytological and functionalcriteriafor the classificationof malignantlymphomata.Br J Cancer 2:29-43. Lenz G, Nagel I, Siebert R, Roschke AV, Sanger W, Wright GW, Dave SS, Tan B, Zhao H, Rosenwald A, Muller-HermelinkHK, Gascoyne RD, Camp0 E, Jaffe ES, Smeland EB, Fisher R1, KuehlWM, ChanWC, StaudtLM (2007): Aberrantimmunoglobulinclass switch recombination and switch translocationsin activated B cell-like diffuse large B cell lymphoma.J Exp Med 204~633-643.

REFERENCES

361

Lenz G. Wright GW. Emre NC, KohlhammerH, Dave SS, Davis RE, CartyS, Lam LT, ShafferAL, Xiao W, Powell J, RosenwaldA, OttG, Muller-HermelinkHK, Gascoyne RD,ConnorsJM.Campo E, JaffeES, Delable J, SmelandEB, Rimsza LM, FisherRI, WeisenburgerDD, ChanWC, Staudt LM (2008): Molecular subtypes of diffuse large B-cell lymphoma arise by distinct genetic pathways. Proc Natl Acud Sci USA 105: 13520- 13525. LepretreS, BuchonnetG, StamatoullasA. LenainP, Duval C, d’AnjouJ,CallatMP, Tilly H, BastardC (2000): Chromosome abnormalitiesin peripheralT-cell lymphoma. Cancer Genet Cytogenet 117~71-79. LetaiAG (2008): Diagnosingandexploitingcancer’saddictionto blocks in apoptosis.Nut Rev Cancer 8:12 1-1 32. Liu H, Ruskon-Fourn~esrraux A, Lavergne-Slove A, Ye H, Molina T, BouhnikY, HamoudiRA, Diss TC, Dogan A, Megraud F, RambaudJC, Du MQ, Isaacson PG (2001): Resistance of t(1 1;18) positive gastricmucosa-associatedlymphoidtissue lymphomato Helicobucter pylori eradication therapy.Luncef 357:3940. Liu H, Ye H, Ruskone-FourmestrauxA, De Jong D, Pileri S, ThiedeC, LavergneA, Boot H, Caletti G, Wundisch T, Molina T, Taal BG, Elena S, Thomas T,Zinzani PL, Neubauer A, Stoke M, Hamoudi RA, Dogan A, lsaacson PG, Du MQ (2002): t( 1 1:18) is a markerfor all stage gastric MALT lymphomas that will not respond to H. pylori eradication. Gastroenlerology 122: 1286-1 294. Ma 2,Cools J, MarynenP, Cui X, SiebertR, Gesk S, SchlegelbergerB, Peeters B, De Wolf-PeetersC, Wlodarska 1. Morris SW (2000): Inv(2)(p23q35) in anaplastic large-cell lymphoma induces constitutiveanaplasticlymphomakinase (ALK) tyrosine kinase activationby fusion to ATIC,an enzyme involved in purine nucleotide biosynthesis. Blood 95:2 144-2149. MacLeod RA, Spitzer D, Bar-Am I, Sylvester JE, KaufmannM, Wernich A, Drexler HG (2000): Karyotypicdissection of Hodgkin’sdisease cell lines revealsectopic subtelomeresand ribosomal DNA at sites of multiple jumping translocations and genomic amplification. Leukemia 14:1803-1 8 14. Maes B, VanhentenrijkV, WlodarskaI, Cools J, PeetersB, MarynenP, de Wolf-PeetersC (2001): The NPM-ALK and the ATIC-ALK fusion genes can be detected in non-neoplasticcells. Am J Pathol 158:2 185-2193. MagrangeasF, LodL L, Wuilleme S, Minvielle S, Avet-Loiseau H (2005): Genetic heterogeneity in multiple myeloma. Leukemia 19:191-1 94. Majid A, Tsoulakis 0, Walewska R, Gesk S, Siebert R, Kennedy DB, Dyer MJ (2007): BCL2 expressionin chronic lymphocyticleukemia:lackof associationwith the BCL2938A>C promoter single nucleotide polymorphism. Blood I 1 I:874-877. Man C, Au WY, Pang A, Kwong YL (2002): Deletion 6q as a recurrentchromosomalaberrationin T-cell large granularlymphocyte leukemia. Cancer Genet Cyrogenet 139:71-74. Mandal AK, Savvidou L, Sleter RM, Cockett W, Wiggins J, Missouris CG (2007): Angiotropic lymphoma:associated chromosomal abnormalities.Eur J fnlern Med 18:432-434. Manolov G, Manolova Y (1972): Markerband in one chromosome 14 from Burkitt lymphomas. Nature 23733-34. ManolovaY, Manolov G, KielerJ, LevanA, Klein G ( 1 979): Genesis of the 1% + markerin Burkitt’s lymphoma.Hereditas 90:5- 10. Mao X, Lillington D, Scarisbrick JJ, Mitchell T, Czepulkowski B, Russell-Jones R, Young B, WhittakerSJ (2002): Molecularcytogenetic analysis of cutaneousT-cell lymphomas:identification of common genetic alterationsin SCzary syndromeand mycosis fungoides. Br J Dermatol 147:464475. MaoX, LillingtonDM, CzepulkowskiB, Russell-JonesR, YoungBD, WhittakerS (2003a): Molecular cytogenetic characterizationof Sdzary syndrome. Genes Chromosomes Cancer 36:250-260.

362

MATURE 8- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

Mao X, Onadim Z, Price EA, Child F, Lillington DM, Russell-Jones R, Young BD, WhittakerS (2003b): Genomic alterationsin blastic naturalkiller/extranodalnaturalkiller-like T cell lymphoma with cutaneous involvement. J Invest Dermatol 121 :6 18-627. Martin-SuberoJI, Gesk S, HarderL, Sonoki T, TuckerPW, SchlegelbergerB, Grote W, Novo FJ, CalasanzMJ, HansmannML, Dyer MJ, Siebert R (2002): Recurrentinvolvementof the REL and BCL L1A loci in classical Hodgkin lymphoma. Blood 9 9 1474-1477. Martin-SuberoJ1, Gesk S, Harder L, Grote W, Siebert R (2003a): lnterphase cytogenetics of hematological neoplasms underthe perspective of the novel WHO classification.Anticancer Res 23:1139-1148. Martin-SuberoJI, Knippschild U, HarderL, BarthTF, Riemke J, GrohmannS, Gesk S,HoppnerJ, MollerP, ParwareschRM,SiebertR (2003b): Segmentalchromosomalaberrationsandcentrosome amplifications: pathogenetic mechanisms in Hodgkin and Reedstemberg cells of classical Hodgkin's lymphoma?kukemiu 17:2214-2219. Martin-SuberoJI, OderoMD. HernandezR, CigudosaJC, AgirreX, Saez B, Sanz-GarciaE, Ardanaz MT, Novo FJ. GascoyneRD, CalasanzMJ,SiebertR (2005): Amplificationof IGWMYCfusion in clinically aggressive IGH/BCL2-positive germinal center B-cell lymphomas. Genes Chromosomes Cancer 43:4 14-423. Martin-SuberoJ1, Klapper W, Sotnikova A, Callet-Bauchu E, HarderL, Bastard C, Schmitz R, GrohmannS, HoppnerJ, Riemke J, BarthTF, Berger F, Bernd HW. Claviez A, Gesk S, Frank GA, KaplanskayaIB, Moller P, ParwareschRM, RiidigerT, Stein H, KuppersR, HansmannML, Siebert R, Deutsche Krebshilfe Network Project Molecular Mechanisms in Malignant Lymphomas (2006): Chromosomal breakpoints affecting immunoglobulin loci are recurrent in Hodgkin and Reed-Stemberg cells of classical Hodgkin lymphoma. Cancer Res 66: 10332-10338. Martin-SuberoJI, IbbotsonR, KlapperW, Michaux L, Callet-BauchuE, BergerF, CalasanzMJ, De Wolf-PeetersC, Dyer MJ, Felman P, GardinerA, Gascoyne RD, Gesk S, HarderL, HorsmanDE, KnebaM, KiippersR, Majid A, Parry-JonesN, Ritgen M, Salido M, Sol6 F,Thiel G, WackerHH, Oscier D, WlodarskaI, Siebert R (2007): A comprehensivegenetic and histopathologicanalysis identifies two subgroupsof B-cell malignancies carryinga t( 14;19)(q32;q13) or variantBCL3translocation.Leukemia 21: 1532-1 544. Mateo M, Mollejo M, Villuendas R, Algara P, Sanchez-Beato M, Madnez P, Piris MA (1999): 7q31-32 allelic loss is a frequent finding in splenic marginal zone lymphoma. Am J Pathol 154:1583-1589. MatutesE, CarraraP. Coignet L, Brito-BabapulleV, VillamorN, WotherspoonA, CatovskyD (1999): FISH analysis for BCL-I rearrangementsand trisomy 12 helps the diagnosis of atypical B cell leukaemias. Leukemia 13:1721-1726. MayrC, SpeicherMR, Kofler DM, BuhmannR, StrehlJ, Busch R, Hallek M, WendtnerCM (2006): Chromosomaltranslocationsareassociated with poor prognosis in chronic Iymphocyticleukemia. Blood 107:742-75 1. MerchantS, Schlefte E, Sanger W. Lai R, Medeiros LJ (2003): MatureB-cell leukemias with more than55% prolymphocytes:reportof 2 cases with Burkittlymphoma-typechromosomaltranslocations involving c-myc. Arch Puthol Lab Med 127:305-309. Micci F, Panagopoulos1, TjennfjordGE, KolstadA, Delabie J, Beiske K, Heim S (2007): Molecular cytogenetic characterizationoft( 14;19)(q32;pl3), a new recurrenttranslocationin B cell malignancies. Virchows Arch 45039-565. Michaux L, WlodarskaI, Theate I, Stul M, Scheiff JM, Deneys V, FerrantA, HagemeijerA (2004): Coexistence of BCLIKCNDIand CMYC aberrationsin blastoid mantle cell lymphoma:a rare finding associated with very poor outcome. Ann Hematoi 83578-583. Migliazza A, Bosch F, KomatsuH, Cayanis E, MartinottiS, ToniatoE, Guccione E, Qu X, Chien M, Murty VV, Gaidano G, InghiramiG, Zhang P, Fischer S, Kalachikov SM,Russo J, Edelman 1,

REFERENCES

363

Efstratiadis A, Dalla-Favera R (200 1 ): Nucleotide sequence, transcriptionmap, and mutation analysisof the I3q14 chromosomalregiondeleted in B-cell chroniclymphocytic leukemia.Blood 97:2098-2104. MikiT, KawamataN, HirosawaS, Aoki N (1994): Gene involved in the 3927 translocationassociated with B-cell lymphoma, BCL5, encodes a Kriippel-likezinc-finger protein. Blood 83:26-32. MitelmanF, JohanssonB, MertensF, editors(2008):MitelmanDatabaseof ChromosomeAberrations in Cancer. Available at http://cgap.nci.nih.gov/Chromosomes/Mitelman. Mitev L. ChristovaS, HadjievE, GuenovaM, OuchevaR, ValkovI, ManolovaY ( 1998):A new variant chromosomal translocationt(2;2)(p23;q23) in CD30+/Ki-1 + anaplastic large cell lymphoma. k u k Lymphoma 28:613-6 16. Miyoshi I, Hiraki S, KimuraI, Miyamoto K, Sat0J (1979): 3 8 translocationin a JapaneseBurkitt’s lymphoma. Experientia 35:742-743. Montoto S , Davies AJ, MatthewsJ, CalaminiciM, Norton AJ,Amess J, Vinnicombe S, WatersR, Rohatiner AZ, Lister TA (2007): Risk and clinical implications of transformationof follicular lymphoma to diffuse large B-cell lymphoma.J Clin Oncol25:2426-2433. Morgan R,Hecht BK, SandbergAA, Hecht F, Smith SD (1986): Chromosome5q35 breakpointin malignanthistiocytosis. N EnglJ Med 3 14:1322. Moms SW, KirsteinMN, ValentineMB, Dittmer KG, ShapiroDN, SaltmanDL, Look AT (1994): Fusion of a kinase gene, ALK, to a nucleolar proteingene, NPM, in non-Hodgkin’s lymphoma. Science 263: 1281-1284. MotokuraT, Bloom T, Kim HG. JuppnerH, RudermanJV, KronenbergHM, ArnoldA ( 1991): A novel cyclin encoded by a bcl1 -linked candidateoncogene. Nature 350512-51 5. MottokA, RennCC, WillenbrockK, HansmannML, BrauningerA (2007): Somatichypermutationof SOCSI in lymphocyte-predominantHodgkinlymphomais accompaniedby high JAK2expression and activation of STATb Blood I 103387-3390. Mullaney BP, Ng VL, HerndierBG, McGrathMS, Pallavicini MG (2000): Comparativegenomic analyses of primaryeffusion lymphoma.Arch Puthol Lab Med 124:824-826. NakamuraS, Ye H, Bacon CM, GoatlyA, Liu H, BanhamAH, VenturaR, MatsumotoT, Iida M, Ohji Y, Yao T, Tsuneyoshi M, Du MQ (2007): Clinical impact of genetic aberrationsin gastric MALT lymphoma: a comprehensiveanalysis using interphase fluorescence in situ hybridisation.Gut 56: 1358-1 363. NakashimaY, TagawaH, Suzuki R,KamanS , KarubeK, OhshimaK,MutaK, NawataH, Morishima Y, NakamuraS, Set0 M (2005):Genome-wide array-basedcomparativegenomic hybridizationof naturalkiller cell lymphomdeukemia:differentgenomic alterationpatternsof aggressiveNK-ccll leukemia and extranodal Nk/T-cell lymphoma, nasal type.. Genes Chromosomes Cancer 44 ~247-255. Nelson BP, Gupta R, Dewald GW, Paternoster SF, Rosen ST, Peterson LC (2007): Chronic lymphocytic leukemia FISH panel: impact on diagnosis. Am J Clin Puthol 128:323-332. Nelson M, Horsman DE, WeisenburgerDD, Gascoyne RD, Dave BJ, Loberiza FR, Ludkovski 0, Savage KJ, ArmitageJO,SangerWG (2008): Cytogeneticabnormalitiesandclinical correlations in peripheralT-cell lymphoma. Br J Huemotof 14 1:461469. Neri A, Chang CC, LombardiL, Salina M, CorradiniP,Maiolo AT, Chaganti RS, Dalla-FaveraR ( I99 I ): B cell 1ymphoma-associated chromosomal translocation involves candidate oncogene lyt- 10, homologous to NF-kappaB p50. Cell 67: 1075-1087. Neri A, Baldini L, Trecca D, Cro L, Poll; E, Maiolo AT (1993): p53 gene mutations in multiple myeloma are associated with advancedformsof malignancy.Blood 8 1 :125- 1 35. Nessling M, Solinas-Told0 S, Lichter P, ReifenbergerG, Wolter M, Moller P, f i b e r H, Bentz M (1 999): Genomic imbalances are rare in hairy cell leukemia. Genes Chromosomes Cancer 26~182-183.

364

MATURE 8- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

NielaenderI, Martin-SuberoJI,WagnerF, Martinez-ClimentJA, SiebertR (2006): Partialuniparental disomy: a recurrent genetic mechanism alternative to chromosomal deletion in malignant lymphoma. h k e m i u 20904-905. NielanderI, Bug S, RichterJ, Giefing M, Martin-SuberoJI, SiebertR (2007): Combiningarray-based approachesfor the identificationof candidate tumor suppressorloci in mature lymphoid neoplasms. APMIS 115:1107-1134. Nilsson T, HoglundM, LenhoffS, RylanderL, Turesson1,WestinJ, MitelmanF, JohanssonB (2003): A pooled analysis of karyotypic patterns, breakpointsand imbalances in 783 cytogenetically abnormal multiple myelomas reveals frequently involved chromosome segments as well as significant age- and sex-related differences. Br J Haemutol 120:960-969. NowakowskiGS, Dewald GW, HoyerJD, PaternosterSF, Stocker0KJ, FinkSR, SrnoleySA, Remstein ED, Phyliky RL, Call TG, ShanafeltTD, Kay NE, Zent CS (2005): Interphasefluorescencein situ hybridizationwith an IGH probeis importantin the evaluationof patientswith a clinical diagnosis of chronic lymphocytic leukaemia.Br J Haematol 130:36-42. O’Donnell KA, Wentzel EA, Zeller KI, Dang CV, Mendell JT (2005): c-Myc-regulatedmicroRNAs modulateE2F1 expression. Nature 435839-843. Offit K, ParsaNZ, GaidanoG. FilippaDA, Louie D, Pan D, JhanwarSC, Dalla-FaveraR, ChagantiRS (1993): 6q deletionsdefinedistinctclinico-pathologic subsetsof non-Hodgkin’slymphoma.Blood 82~2157-2162. OhnoH (2004): Pathogeneticrole of BCL6 translocationin B-cell non-Hodgkin’slymphoma.Histol Histopathol 19:637-650. OhnoH (2006): Pathogeneticandclinical implicationsof non-immunoglobulin;BCL6translocations in B-cell non-Hodgkin’slymphoma.J Clin Exp Hematop 46:43-53. OhnoH, TakimotoG, McKeithanTW (1 990): The candidateproto-oncogenebcl-3 is relatedto genes implicated in cell lineage determinationand cell cycle control. Cell 60:991-997. Ohno H. Ueda C, Akasaka T (2000): The t(9;14)(p13;q32) translocationin B-cell non-Hodgkin’s lymphoma. h k Lymphoma 3 6 : 4 3 5 4 5 . Oscier DG, MatutesE, GardinerA, Glide S, Mould S, Brito-BabapulleV, Ellis J, CatovskyD (1994): Cytogenetic studies in splenic lymphomawith villous lymphocytes. Br J Huematol85:487491. OshiroA, TagawaH, OhshimaK, KarubeK, Uike N, TashiroY,UtsunomiyaA, MasudaM, TakasuN, Nakamura S, MorishimaY,Set0 M (2006): Identificationof subtype-specificgenomic alterations in aggressive adult T-cell leukemiallymphoma.Blood 107:4500-4507. OstergaardM, LindbjergAndersenC, PedersenB, Koch J, Nielsen B (2001): Recurrentimbalances involving chromosome 5 and 7q22q35 in hairy cell leukemia: a comparativegenomic hybridization study. Genes Chromosomes Cancer 30:218-219. Ott G , Kalla J, Ott MM, Schryen B, KatzenbergerT, Muller JG, Muller-HermelinkHK (1997a): Blastoid variantsof mantle cell lymphoma:frequentbcl- 1 rearrangementsat the majortranslocation cluster region and tetraploidchromosomeclones. Blood 8 9 1421-1429. Ott G, KatzenbergerT, GreinerA, KallaJ, RosenwaldA, HeinrichU, Ott MM, Muller-HermelinkHK ( I 997b): The t(1 1 ;I8)(q21;q21) chromosometranslocationis a frequentand specific aberrationin low-grade but not high-grade malignant non-Hodgkin’s lymphomas of the mucosa-associated lymphoid tissue (MALT-)type. Cancer Res 57:3944-3948. OttMM, RosenwaldA, KatzenbergerT, DreylingM, KrumdiekAK, KallaJ, GreinerA, OttG, MullerHermelink HK (2000): Marginal zone B-cell lymphomas (MZBL) arising at different sites representdifferent biological entities. Genes Chromosomes Cancer 28:38&386. OttG , KatzenbergerT,LohrA, KindelbergerS, RudigerT, WilhelmM, KallaJ, Rosenwald A, Muller JG. Ott MM, Muller-Hermelink HK (2002): Cytomorphologic, immunohistochemical, and cytogenetic profiles of follicular lymphoma: 2 types of follicular lymphoma grade 3. Blood 99:380&3812.

REFERENCES

365

Ouillette P, Erba H, Kujawski L, Kaminski M, Shedden K, Malek SN (2008): Integratedgenomic profiling of chronic lymphocytic leukemia identifies subtypes of deletion 13q14. CancerRes 68: 10I 2-1 021. Pasqualucci L, Neumeister P, Goossens T, NanjangudG, ChagantiRS, KuppersR, Dalla-FaveraR (200 1 ): Hypermutationof multiple proto-oncogenes in B-cell diffuse large-cell lymphomas. Nature 4 12:341-346. PasqualucciL, Migliazza A, Basso K, HouldsworthJ, ChagantiRS, Dalla-RveraR (2003): Mutations of the BCL6 proto-oncogenedisruptits negative autoregulationin diffuse largeB-cell lymphoma. Blood 101:2914-2923. PasqualucciL. CompagnoM, HouldsworthJ, Monti S, GrunnA, Nandula SV, Aster JC, Murty VV, ShippMA, Dalla-FaveraR (2006): Inactivationof the PRDMI/BLIMPIgene in diffuse largeB cell lymphoma. J Exp Med 203:311-317. PCrez-Sim6nJA, Garcia-SanzR, TaberneroMD, Almeida J, Gonzalez M, Fernhdez-CalvoJ, Moro MJ, HernandezJM, San Miguel JF, OrfaoA (1998): Prognosticvalue of numericalchromosome aberrations in multiple myeloma: a FISH analysis of 15 different chromosomes. Blood 91:3366-3371. Pinyol M, Bea S, Pla L, RibragV, Bosq J, RosenwaldA, CampoE, JaresP (2007): lnactivationof RB 1 in mantle-cell lymphoma detected by nonsense-mediatedmRNA decay pathway inhibition and microarrayanalysis. Blood 1095422-5429. Poppe B, De Paepe P, Michaux L. Dastugue N, BastardC, HerensC, MoreauE, Cavazzini F, Yigit N, Van Limbergen H, De Paepe A, PraetM,De Wolf-PeetersC, WlodarskaI, Speleman F (2005): PAXS/IGH rearrangementis a recurrentfinding in a subset of aggressive B-NHL with complex chromosomal rearrangements.Genes Chromosornes Cuncer 44:2 18-223. Pospisilova H, Baens M, Michaux L, Stul M, Van HummelenP, Van Loo P, VermeeschJ, JarosovaM, ZemanovaZ, Michalova K, Van den Berghe I, Alexander HD, Hagemeijer A, VandenbergheP, Cools J, De Wolf-PeetersC, MarynenP, Wlodarska1 (2007): Interstitialdel( 14)(q) involving IGH: a novel recurrentaberrationin B-NHL. Leukemia 2 I :2079-2083. ProchazkovaM. ChevretE, Beylot-BarryM, SobotkaJ, VergierB, Delaunay M, TurmoM, FerrerJ, Kuglik P, Merlio JP (2003): Chromosomalimbalances:a hallmarkof tumourrelapse in primary cutaneousCD30 + T-cell lymphoma.J Puthol201 :421-429. PrzybylskiGK, Dik WA, WanzeckJ, GrabarczykP, MajunkeS, Martin-SuberoJI, SiebertR, E l k e n G, Ludwig WD, VerhaafB, van Dongen JJ,SchmidtCA, LangerakAW (2005): Disruptionof the BCLI 1B gene throughinv(14)(qI1.2q32.3 1) results in the expression of BCLl IB-TRDC fusion transcriptsand is associated with the absence of wild-type BCLI IB transcriptsin T-ALL. kukemiu 19:201-208. RajkumarS , Fonseca R, Lacy M. Witzig T, Lust J, Greipp P, TherneauT, Kyle R, Litzow M, Gertz M (1999): Abnormal cytogenetics predict poor survival after high-dose therapy and autologous blood cell transplantationin multiple myeloma. Bone Marrow Transplant 24: 497-503. Rao PH, CigudosaJC, Ning Y, CalasanzM3,Iida S, TagawaS, Michaeli J, Klein B, Dalla-FaveraR, JhanwarSC, Ried T, ChagantiRS ( 1998): Multicolorspectralkaryotypingidentifiesnew recurring breakpointsand translocationsin multiple myeloma. Blood 92:1743-1 748. Reddy K, Satyadev R, BoumanD. HibbardMK, Lu G, Paolo R (2006): Burkittt(8; 14)(q24;q32)and crypticdeletion in a CLLpatient:reportof a case andreview of literature.Cancer Genet Cytogenel 166:12-21. Renne C, Martin-SuberoJl, HansmannML, Siebert R (2005): Molecular cytogenetic analyses of immunoglobulinloci in nodularlymphocytepredominantHodgkin’slymphomareveal a recurrent IGH-BCL6juxtaposition.J Mol Diagn 7:352-356. Ried K, Finnis M, Hobson L, MangelsdorfM. Dayan S, NancarrowJK, WoollattE, KremmidiotisG, GardnerA, VenterD, Baker E, RichardsRI (2000): Common chromosomalfragile site FRA16D

366

MATURE B- AND T-CELL NEOPLASMS AND HODGKlN LYMPHOMA

sequence: identificationof the FOR gene spanning FRAl6D and homozygous deletions and translocationbreakpointsin cancercells. Hum Mol Genet 9:1651-1 663. RipollCs L, OrtegaM, OrtuiioF, Gonzilez A, LosadaJ, OjangurenJ, Soler JA, BerguaJ, Coll MD, CaballinMR (2006): Geneticabnormalitiesand clinical outcome in chroniclymphocyticleukemia. Cancer Genet Cytogenet 17157-64. RonchettiD, Finelli P, RicheldaR, BaldiniL, Rocchi M, Viggiano L, CuneoA, Bogni S, FabrisS, LombardiL, Maiolo AT, Neri A (1999): Molecularanalysis of I l q l 3 breakpointsin multiple myeloma.Blood 93: 133&1337. RosenbergCL, Wong E, Petty EM,Bale AE, TsujimotoY,HarrisNL,ArnoldA (1991): PRADI, a candidateBCLI oncogene:mappingand expressionin centrocyticlymphoma.Proc Natl Acad Sci USA 88:9638-9642. RosenwaldA, WrightG,ChanWC,ConnorsJM,CampoE, FisherR1,GascoyneRD,Muller-Hermelink HK,SmelandEB,GiltnaneJM, HurtEM,ZhaoH,AverettL,YangL, WilsonWH.JaffeES,SimonR, SangerWG,DaveBJ, KlausnerRD,PowellJ,DuffeyPL, Long0DL,GreinerTC,WeisenburgerDD, LynchJC,Vose J,ArmitageJO,MontserratE, L6pez-GuillermoA, GroganTM, MillerTP,LeBlanc M, Ott G, Kvaloy S, Delabie J, Holte H, KrajciP, Stoke T, StaudtLM, LymphomaLeukemia Molecular Profiling Project (2002): The use of molecular profiling to predict survival after chemotherapyfor diffuse large-B-cell lymphoma.N Engl J Med 346:1937- 1947. RosenwaldA, WrightG, Leroy K,Yu X,GaulardP, Gascoyne RD, ChanWC, Zhao T, HaiounC, GreinerTC, WeisenburgerDD, LynchJC, Vose J. ArmitageJO, SmelandEB, Kvaloy S, Hoke H, DelahieJ, CampoE, MontserratE, Lopez-GuillermoA, Ott G, Muller-HermelinkHK, Connors JM,BrazielR, GroganTM, FisherR1, MillerTP, LeBlancM, ChiorazziM, ZhaoH, Yang L, Powell J, Wilson WH. Jaffe ES, Simon R, Klausner RD, StaudtLM (2003): Moleculardiagnosis of primarymediastinalB cell lymphomaidentifiesa clinicallyfavorablesubgroupof diffuselargeB cell lymphomarelatedto Hodgkinlymphoma.J Exp Med 1982351-862. RossCW,OuillettePD, SaddlerCM, SheddenKA, MalekSN (2007):Comprehensiveanalysisof copy numberand allele statusidentifiesmultiplechromosomedefects underlyingfollicularlymphoma pathogenesis.CIin Cancer Res 13:4777-4785. Rubio-MoscardoF, ClimentJ, SiebertR, Piris MA, Martin-Subero JI, Nielander1, Garcia-CondeJ, Dyer MJ, Terol MJ, Pinkel D, Martinez-ClimentJA (2005): Mantle-cell lymphomagenotypes definea leukemicsubgroupof diseaseandpredictpatient identifiedwith CGHto BAC microarrays outcome.Blood 105:4445-4454. Ruiz-BallesterosE, Mollejo M, Mateo M, AlgaraP, MartinezP, Piris MA (2007): MicroRNAlosses in the frequentlydeleted region of 7q in SMZL.LRukemia 21:2547-2549. RuminyP, JardinF, PicquenotJM,GaulardP, ParmentierF, BuchonnetG, MaisonneuveC, Tilly H, BastardC (2006): Two patternsof chromosomalbreakpointlocationson the immunoglobulin heavy-chainlocus in B-cell lymphomaswith t(3;14)(q27:q32):relevanceto histology.Oncogene 25:49474954. Siez B, Martin-SuberoJI, GuillCn-GrimaF. OderoMD, ProsperF, CigudosaJC. HarderL, Calasanz MJ, Siebeh R (2004): Chromosomalabnormalitiesclusteringin multiplemyeloma revealscytogenetic subgroupswith nonrandomacquisitionof chromosomalchanges.Leukemia I8:654-657. Salavema I, Zettl A, Bea S, MorenoV, Valls J, HartmannE, Ott G, WrightG , Lopez-GuillermoA, Chan WC, WeisenburgerDD, Gascoyne RD, Grogan TM. Delabie J, Jaffe ES, MontserratE, Muller-HermelinkHK, StaudtLM, RosenwaldA, CampoE (2007): Specific secondarygenetic alterationsin mantle cell lymphomaprovide prognostic informationindependentof the gene expression-basedproliferationsignature.J Clin Oncol25: 1216-1222. Salavema I, Bea S, Lopez-GuillermoA, Lespinet V, Pinyol M, BurkhardtB, LamantL. Zettl A, Horsman D. GascoyneR, OttG, SiebertR, Delsol G, CampoE (2008a):Genomicprofilingreveals differentgenetic aberrationsin systemic ALK-positiveand ALK-negativeanaplasticlarge cell lymphomas.Br J Haematol 140516-526.

REFERENCES

367

SalaverriaI, Zettl A, Bea S, HartmannEM, Dave SS, WrightGW, Boerma EJ. Kluin PM, OttG, Chan WC, WeisenburgerDD, Lopez-GuillermoA, Gascoyne RD, Delable J, Rimsza LM, Braziel RM, Jaffe ES, StaudtLM, Muller-HermelinkHK, Camp0E. Rosenwald A; Leukemiaand Lymphoma MolecularProfilingProject(LLMPP)(2008b): Chromosomalalterationsdetected by comparative genomic hybridizationin subgroupsof gene expression-definedBurkitt'slymphoma.Huemutologicu 93:1327- 1334. Sambani C. Trafalis DT, Mitsoulis-Mentzikoff C, Poulakidas E, Makropoulos V. Pantelias GE, Mecucci C (2001 ): Clonal chromosomerearrangementsin hairy cell leukemia: personal experience and review of literature.Cancer Genet Cytogenet 129:138-144. Sanchez-IzquierdoD, Buchonnet G, Siebert R, Gascoyne RD, Climent J, KarranL. Mann M, Blesa D, Horsman D, Rosenwald A, Staudt LM, Albertson DG, Du MQ, Ye H, Marynen P, Garcia-CondeJ, Pinkel D, Dyer MJ, Martinez-ClimentJA (2003): MALT1 is deregulatedby both chromosomal translocation and amplification in B-cell non-Hodgkin lymphoma. Blood 101 :4539-4546. Sander S, Bullinger L, Leupolt E, Benner A, Kienle D, KatzenbergerT, Kalla I, Ott G, MullerHermelink HK, Barth TF, Moller P, Lichter P, Dohner H, StilgenbauerS (2008): Genomic aberrationsin mantle cell lymphoma detected by interphase fluorescence in situ hybridization. Incidence and clinicopathologicalcorrelations.Haemutologicu 93:680-687. SantraM,Zhan F. Tian E, Barlogie B, Shaughnessy J Jr (2003): A subset of multiple myeloma harboring the t(4;14)(pI6;q32) translocation lacks FGFR3 expression but maintains an IGW MMSET fusion transcript.Blood I0 I :2374-2376. SatterwhiteE. Sonoki T. Willis TG, HarderL, Nowak R, Amola EL, Liu H, Price HP, Gesk S, Steinemann D, Schlegelberger B, Oscier DG, Siebert R, Tucker PW, Dyer MJ (2001): The BCL I 1 gene family: involvement 0 1 BCLI 1 A in lymphoid malignancies. Blood 98:34 13-3420. Savage KJ, Monti S, Kutok JL, CattorettiG, Neuberg D, De Leva1 L, KurtinP, Dal Cin P, Ladd C, FeuerhakeF, AguiarRC, Li S. Salles G, BergerF, Jing W, PinkusGS, HabermannT, Dalla-Favera R, HarrisNL, AsterJC,GolubTR, ShippMA (2003): Themolecularsignatureof mediastindlarge B-cell lymphomadiffersfromthatof otherdiffuselargeB-cell lymphomasandsharesfeatureswith classical Hodgkin lymphoma. Blood 102:3871-3879. Savage KJ, Hams NL, Vose JM, UllrichF, Jaffe ES, ConnorsJM, Rimsza L, Pileri SA, ChhanabhaiM, Gascoyne RD, Armitage JO, Weisenburger DD (2008): ALK-negative anaplastic large-cell lymphoma (ALCL) is clinically and immunophenotypicallydifferent from both ALK-positive ALCL and peripheralT-cell lymphoma, not otherwise specified: report from the International PeripheralT-cell LymphomaProject. Blood 1 1 1 5496-5504. SawyerJR, LukacsJL, MunshiN, DesikanKR, Singhal S, MehtaJ, Siege1 D, ShaughnessyJ, Barlogie B ( 1 998): Identificationof new nonrandomtranslocationsin multiple myeloma with multicolor spectral karyotyping.Blood 92:42694278. Sawyer JR, LukacsJL, Thomas EL, Swanson CM, Goosen LS, SammartinoG, GillilandJC, Munshi NC, Tricot G, ShaughnessyJD Jr, Barlogie'B (2001): Multicolourspectralkaryotypingidentifies new translocationsand a recurringpathway for chromosome loss in multiple myeloma. Br J Huemutol I 12:167- 174. Schaffner C, StilgenbauerS, Rappold GA, Dohner H, Lichter P (1999): Somatic ATM mutations indicate a pathogenic role of ATM in B-cell chronic lymphocytic leukemia. Blood 94~748-753. SchlegelbergerB, HimmlerA, BartlesH, Kuse R, SterryW, GroteW ( 1 994a): Recurrentchromosome abnormalitiesin peripheralT-cell lymphomas. Cancer Genet Cytogenet 78: 15-22. SchlegelbergerB, HimmlerA, GaddeE, GroteW,FellerAC, LennertK (1994b): Cytogeneticfindings in peripheralT-cell lymphomasas a basis fordistinguishinglow-gradeandhigh-gradelymphomas. Blood 83~505-51 1.

368

MATURE 6-AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

SchlegelbergerB, Weber-MatthiesenK, HimmlerA, BartelsH, SonnenR, KuseR, FellerAC, GroteW (1 994c): Cytogenetic findings and results of combined immunophenotypingand karyotypingin Hodgkin’s disease. Leukemia 8:72-80. SchlegelbergerB, Zhang Y, Weber-MatthiesenK, GroteW (1994d): Detection of aberrantclones in nearly all cases of angioimmunoblastic lymphadenopathy with dysproteinemia-type T-cell lymphoma by combined interphaseand metaphasecytogenetics. Blood 84:264&2648. Schlegelberger B. Zwingers T, Hohenadel K, Henne-Bruns D, Schmitz N, Haferlach T, Tuier C, Bartels H. Sonnen R, Kuse R,et al. (1996): Significance of cytogenetic findings for the clinical outcome in patientswith T-cell lymphomaof angioimmunoblasticlymphadenopathytype. J Clin Oncol 14593-599. Schlegelberger B, Zwingers T, HarderL, Nowotny H, Siebert R, Vesely M, Bartels H, Sonnen R. HopfingerG , Nader A, Ott G, Muller-HermelinkK, Feller A, Heinz R, Kiel-Wien-Lymphoma Study Group(1999): Clinicopathogeneticsignificance of chromosomalabnormalitiesin patients with blastic peripheralB-cell lymphoma. Blood 94:3 1 14-3120. SchmitzR,RennCC,RosenquistR,TinguelyM,DistlerV, MenestrinaF,LestaniM,StankovicT,Austen B, Briuninger A, HansmannML, KiippersR (2005): Insights into the multisteptransformation process of lymphomas: IgH-associated translocationsand tumor suppressorgene mutationsin clonally relatedcomposite Hodgkin’sand non-Hodgkin’slymphomas.LewGemiu 1 9 1452-1458. SchopRF,Kuehl WM, Van WierSA, AhmannGJ, Price-TroskaT,Bailey RJ,JalalSM, Qi Y,Kyle RA, GreippPR, Fonseca R (2002): Waldenstrommacroglobulinemianeoplastic cells lack immunoglobulin heavy chain locus translocationsbut have frequent6q deletions. Blood 100:299&3001. SchradersM, de Jong D, Kluin P, Groenen P, van Krieken H (2005): Lack of Bcl-2 expression in follicular lymphomamay be caused by mutationsin the BCL2 gene or by absence of the t( 14;18) translocation.J Pathol205:329-335. Schwaenen C, Wessendorf S, Kestler HA, Dohner H, Lichter P, Bentz M (2003): DNA microarray analysis in malignant lymphomas.A m Hematol82:323-332. SchwaenenC, Nessling M,WessendorfS, Salvi T, WrobelG, RadlwimmerB. KestlerHA, Haslinger C, StilgenbauerS, DohnerH, Bentz M, LichterP (2004): Automatedarray-basedgenomicprofiling in chronic lymphocytic leukemia: development of a clinical tool and discovery of recurrent genomic alterations. Proc Nuti Acud Sci USA 10 I :1039- 1044. SchwaenenC, ViardotA, BergerH, BarthTF,BentinkS, DohnerH, Enz M, FellerAC, HansmannML, Hummel M, KestlerHA, KlapperW,KreuzM, Lenze D, LoefflerM, MollerP, Muller-Hennelink HK, Ott G. Rosolowski M, RosenwaldA, Ruf S, SiebertR, Spang R, Stein H, TruemperL, Lichter P, Bentz M, Wessendorf S (2009): Microarray-basedgenomic profiling reveals novel genomic aberrationsin follicular lymphoma which associate with patient survival and gene expression status. Genes ChromosomesCancer48:39-54. Segeren CM, Sonneveld P,van der Holr B, Vellenga E, Croockewit AJ, Verhoef GE, CornelissenJJ, SchaafsmaMR, van Oers MH, WijermansPW, Fibbe WE, WittebolS, SchoutenHC, van Manvijk Kooy M, Biesma DH, Baars JW, Slater R, SteijaertMM, Buijt 1, LokhorstHM,Dutch-Belgian Hemato-Oncology Cooperative Study Group (2003): Overall and event-free survival are not improvedby the use of myeloablative therapy following intensifiedchemotherapyin previously untreated patients with multiple myeloma: a prospective randomized phase 3 study. Blood 101:2144-215 I . SellmannL, Gesk S, WalterC, Ritgen M,HarderL, Martin-SuberoJI, SchroersR, SiemerD, Nuckel H,Dyer MJ, Diihrsen U, Siebert R, Diirig J, Kiipprs R (2007): Tnsomy 19 is associated with trisomy 12 and mutated IGHV genes in B-chronic lymphocytic leukaemia. Br J Haemutol 138~217-220. Sen F, Lai R. Albitar M (2002): Chroniclymphocytic leukemia with t( 14;18) and trisomy 12. Arch Puthol Lab Med 126:1543-1 546.

REFERENCES

369

Shaughnessy J, Tian E, Sawyer I, Bumm K, Landes R, Badros A, MorrisC, Tricot G, Epstein J, Barlogie B (2000): High incidence of chromosome 13 deletion in multiple myeloma detected by multiprobeinterphaseFISH. Blood 96: 1505-15 1 I. ShaughnessyJ Jr,GabreaA, Qi Y, BrentsL, ZhanF, TianE, SawyerJ, Barlogie B, BergsagelPL, Kuehl M (2001): Cyclin D3 at 6p21 is dysregulated by recurrentchromosomal translocations to immunoglobulinloci in multiple myeloma. Blood 98:2 17-223. Shou Y, MartelliML, GabreaA, Q; Y, BrentsLA, Roschke A, Dewald G, Kirsch IR, Bergsagel PL, Kuehl WM (2000): Diverse karyotypicabnormalitiesof the c-myc locus associated with c-myc dysregulationand tumorprogressionin multiple myeloma. ProcNutl Acud Sci USA 97:22&233. SiebertR. RosenwaldA, StaudtLM, MorrisSW (200 I ): Molccularfeaturesof B-cell lymphoma.Curr Opin Oncol 1 3 314-324. Siu LL, Wong KF, Chan JK, Kwong YL ( I 999): Comparativegenomic hybridizationanalysis of naturalkiller cell lymphoma/leukemia.Recognition of consistent patternsof genetic alterations. Am J Puthol 155:1419-1425. Smadja NV, Bastard C, BrigaudeauC, Leroux D, FruchartC, Groupe Franpisde Cytogknetique HCmatologique(2001): Hypodiploidy is a majorprognostic factor in multiple myeloma. Blood 98:222%2238. Sol6 F, Salido M, EspinetB, GarciaJL,MartinezClimentJA, Granada1, HernandezJM,Benet I, Pins MA, Mollejo M, MartinezP, VallespiT, Doming0 A, SerranoS,WoessnerS, FlorensaL (2001): Splenic marginalzone B-cell lymphomas:two cytogenetic subtypes, one with gain of 3q and the other with loss of 7q. Haemutologica 8671-77. Sonoki T, HarderL, HorsmanDE, KarranL, Taniguchi1, Willis TG, Gesk S, SteinemannD, Zucca E, SchlegelbergerB, Sol6 F, MungallAJ,Gascoyne RD, Siebert R, Dyer MJ (2001): Cyclin D3 is a target gene of t(6;14)(p21.1;q32.3) of matureB-cell malignancies. Blood 98:2837-2844. Sonoki T, TatetsuH, Nagasaki A, Hata H (2007): Molecular cloningof translocationbreakpointfrom der(8)t(3;8)(927;q24)definesjuxtapositionof downstreamof C-MYCandupstreamof BCM. Int J Hemulo1 8 6 196198. Soulier J, Pierron G, Vecchione D, GarandR, Brizard F, Sigaux F, Stem MH, Aurias A (2001): A complex patternof recurrentchromosomal losses and gains in T-cell prolymphocyticleukemia. Genes Chromosornes Cancer 3 1 :248-254. Stem MH, Soulier J, Rosenzwajg M, NakaharaK. Cankj-KlainN, Aurias A, Sigaux F, Kirsch IR ( 1993):MTCP-I :a novel gene on the humanchromosomeXq28 translocatedto the T cell receptor alphddeltalocus in matureT cell proliferations.Oncogene 8:2475-2483. StilgenbauerS . Dohner H, Bulgay-MorschelM, Weitz S, Bentz M, LichterP ( 1993):High frequency of monoallelic retinoblastoma gene deletion in B-cell chronic lymphoid leukemia shown by interphasecytoyenetics. Blood 81 :2118-2124. StilgenbauerS, Leiipolt E, Oh1 S, Weiss G, SchroderM, Fischer K, Bentz M, Lichter P, Dohner H (1995): Heterogeneity of deletions involving RB-I and the Dl3325 locus in B-cell chronic lymphocytic lcukemiarevealed by fluqescence in situ hybridization.Cuncer Res 55: 3475-3477. StilgenbauerS,Liebisch P,JamesMR, SchroderM,SchlegelbergerB, FischerK,Bentz M,LichterP, Dohner H ( I 996): Molecular cytogenetic delineation of a novel critical genomic region in chromosome bands 1 lq22.3-923. I in lymphoproliferativedisorders. Proc Nutl Acad Sci USA 93:11837-11841. (Erratumin Proc NutlAcadSci USA, 1996, 93:14992) StilgenbauerS,SchaCfnerC,LitterstA, LiebischP, GiladS.Bar-ShiraA, JamesMR, LichterP,DiihnerH (1 997): Biallelic mutationsin the ATM gene in T-prolymphocyticleukemia.Nut Med3:I 155- I 159. StilgenbauerS. Bullinger L, Benner A. WildenbergerK, Bentz M, Diihner K, Ho AD, Lichter P, Dohiier H ( 1999): Incidenceandclinical significanceof 6q deletionsin B cell chronic lymphocytic leukemia. Leukemia 13:1331-1334.

370

MATURE B- AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

StilgenbauerS, LichterP, DiihnerH (2000): Geneticfeaturesof B-cell chroniclymphocyticleukemia. Rev Clin Exp Hematol4:48-72. StilgenbauerS, SanderS, BullingerL, BennerA, LeupoltE, WinklerD, KroberA, KienleD, LichterP, Dohner H (2007): Clonal evolution in chronic lymphocytic leukemia: acquisitionof high-risk genomic aberrationsassociated with unmutatedVH, resistanceto therapy,and short survival. Haematologica 92: 1242-1 245. Stocker0KJ, Fink SR, Smoley SA, PaternosterSF, ShanafellTD, Call TG, Zent CS, Van Dyke DL. Kay NE, Dewald GW (2006): Metaphasecells with normal G-bandshave cryptic interstitial deletionsin 13q14 detectableby fluorescencein situ hybridizationin B-cell chroniclymphocytic leukemia. Cancer Genet Cytogenet 166:152-156. StreubelB, LamprechtA, DierlammJ, CerroniL, StolteM, OttG, RadererM, ChottA (2003):t( 14;18) (q32;q21)involving IGHand MALT1is a frequentchromosomalaberrationin MALTlymphoma. Blood 101:2335-2339. Streubel B, Chott A, HuberD, ExnerM, JagerU, Wagner0, Schwarzinger1 (2004a):Lymphomaspecific geneticaberrationsin microvascularendothelialcells in B-cell lymphomas.N En81 J Med 35 1:250-259. StreubelB, Simonitsch-Klupp1, MullauerL, LamprechtA, HuberD, SiebertR. StolteM, TrautingerF, Lukas J, Piispok A, FormanekM, Assanasen T. Muller-HemelinkHK, CerroniL. RadererM, Chott A (2004b): Variable frequenciesof MALT lymphoma-associatedgenetic aberrationsin MALT lymphomasof differentsites. Leukemia 18: 1722-1726. StreubelB, VinatzerU, LamprechtA, RadererM, ChottA (2005): t(3;14)(p14.l;q32)involving IGH and FOXPI is a novel recurrentchromosomal aberrationin MALT lymphoma. Leukemia 19:652-658. Streubel B, Scheucher B, Valencak J, Hubex D, PetzelbauerP, TrautingerF, WeihsengruberF, MannhalterC, CerroniL, Chott A (2006a): Molecularcytogenetic evidence of t(14;18)(1GH; BCL2) in a substantialproportionof primarycutaneousfollicle center lymphomas.Am J Surg Pathol30:529-536. StreubelB, VinatzerU,WillheimM,RadererM,ChottA (2006b):Novel t(5;9)(q33;q22)fuseslTKtn SYK in unspecified peripheralT-cell lymphoma.Leukemia 20:313-318. SwerdlowSH,Camp0E, HarrisNL, JaffeES, Pileri SA, SteinH. ThieleJ,VardimanJW (Eds.)(2008): WHO Classification of Tumors of Haematopoietic and Lymphoid Tissues. LARC, Lyon. SzymanowskaN, KlapperW, Gesk S, KuppersR, Martin-SuberoJ1, SiebertR (2008):BCL2andBCL3 are recurrenttranslocationpartnersof the IGH locus. Cancer Genet Cytogenet 186:110-114. TagawaH, KamanS, Suzuki R, Matsuo K, Zhang X, Ota A. MorishimaY, NakamuraS, Set0 M (2005a):Genome-widearray-basedCGHformantlecell lymphoma:identificatianof homozygous deletions of the proapoptoticgene BIM. Oncogene 24: 1348-1 358. Tagawa H, SuguroM, Tsuzuki S, Matsuo K, Kaman S, OhshimaK, Okamoto M, Morishima Y, NakamuraS, Set0M (2005b):Comparisonofgenomeprofilesforidentificationofdistinctsubgroups of diffuselargeB-cell lymphoma.Blood 106: 1770-1777. (Erratumin Blood, 2006, 107:3052) Tam W, Gomez M, ChadburnA, Lee JW,Chan WC, Knowles DM (2006): Mutationalanalysis of PRDMI indicatesa tumor-suppressor role in diffuselargeBcell lymphomas.Blood 107:409@4100. TarteK, De Vos I, ThykjaerT, ZhanF, Fiol G, CostesV, RkmeT, Legouffe E, Rossi JF,Shaughnessy3 Jr, 0rntofITF,Klein B (2002): Generationof polyclonal plasmablastsfrom peripheralblood B cells: a normalcounterpartof malignantplasmablasts.Blood 100:I 113-1 122. TaubR, KirschI, MortonC, LenoirG, Swan D, TronickS, AaronsonS, LederP (1 982): Translocation of the c-myc gene into the immunoglobulinheavy chain locus in humanBurkittlymphomaand murineplasmacytomacells. ProcNatl Acad Sci USA 797837-784 I. ThomadakiH, Scorilas A (2006): BCL2 family of apoptosis-relatedgenes: functionsand clinical implicationsin cancer.Cril Rev Clin Lab Sci 43: 1-67.

REFERENCES

371

ThornsC, Bastian B, Pinkel D, RoydasguptaR, Fridlyand3, Merz H, KrokowskiM, BerndHW,Feller AC (2007): Chromosomal aberrationsin angioimmunoblasticT-cell lymphoma and peripheral T-cell lymphoma unspecified: a matrix-based CGH approach. Genes Chromosomes Cancer 46:37-44. Tilly H, BastardC, Halkin E, LenormandB, Bizet M,Dauce JP, Lees 0, MonconduitM, Piguet H (1988): Del( 14)(q22) in diffuse B-cell lymphocytic lymphoma. Am J Clin futhol89:109-1 13. Tilly H, Rossi A, StamatoullasA, LenormandB, Bigorgne C. Kunlin A, MonconduitM, BastardC ( 1994): Prognostic value of chromosomal abnormalities in follicular lymphoma. Blood 84: 1043-1 049. TortF, Pinyol M, PulfordK, RoncadorG,HernandezL, Nayach1, Kluin-NelemansHC, Kluin P, Touriol C, Delsol G, Mason D, Camp0 E (2001): Molecularcharacterizationof a new ALK translocation involving moesin (MSN-ALK) in anaplasic large cell lymphoma.Lab invest 8 1:419-426. TouriolC, GreenlandC, LamantL, Pulford K, BernardF, Rousset T, Mason DY, Delsol G (2000): Furtherdemonstrationof the diversityof chromosomalchanges involving 2p23 in ALK-positive lymphoma: 2 cases expressing ALK kinase fused to CLTCL (clathrinchain polypeptide-like). Blood 95:3204-3207. TricotG, Barlogie B, JagannathS, BracyD, MattoxS. Vesole DH, Naucke S, SawyerJR (1995): Poor prognosis in multiple myeloma is associated only with partialor complete deletions of chromosome 13 or abnormalitiesinvolving I Iq and not with other karyotype abnormalities. Blood 86:4250-4256. TroussardX , Mauvieux L, Radford-WeissI, Rack K, Valensi F, GarandR, VekemansM, FlandrinG, MacintyreEA ( I 998): Genetic analysis of splenic lymphoma withvillous lymphocytes:a Groupe Franpisd’ Htmatologie Cellulaire(GFHC) study. Br J Haematol 101:712-72 I . Tsujimoto Y, Finger LR, Yunis J, Nowell PC, Croce CM (1984): Cloning of the chromosome breakpoint of neoplastic B cells with the t( 14;18) chromosome translocation. Science 226: 1097- 1099. TsujimotoY,GorhamJ, CossmanJ, Jaffe E, Croce CM (1985): The t( 14: 18) chromosometranslocations involved in B-cell neoplasms result from mistakes in VDJ joining. Science229:1390-1393. TsukasakiK, KrebsJ,Nagai K, TomonagaM, KoefflerHP, BartramCR, JauchA (2001 ): Comparative genomic hybridization analysis in adult T-cell IeukemiaAymphoma:correlation with clinical course. Blood 97:3875-3881. VaandragerJW. SchuuringE, PhilippoK, Kluin PM (2000): V(D)J recombinase-mediatedtransposition of the BCL2 gene to the IGH locus in follicular lymphoma.Blood 96: 1947-1 952. VaghefiP, MartinA, Privot S, CharlotteF, Camilleri-BroetS, Barli E, Davi F, GabarreJ, RaphaelM, Poirel HA (2006): Genomic imbalances in AIDS-related lymphomas: relation with tumoral Epstein-Ban virus status. AIDS 20:2285-229 1. Van Den BergheH, LouwagieA, Broeckaert-VanOrshovenA. David C,VerwilghenR, MichauxJL, Sokal G (1979): Philadelphia chromosome in human multiple myeloma. J Natl Cancer lnst 6 3 ~ 11-16. Van Den Neste E, Robin V. FrancartJ, HagemeijerA, Stul M, VandenbergheP, Delannoy A, Sonet A, Deneys V. Costantini S, FerrantA. Robert A, Michaux L (2007): Chromosomaltranslocations independently predict treatmentfailure, treatment-freesurvival and overall survival in B-cell chronic lymphocytic leukemia patients treatedwith cladribine.Leukemia 2 I :1715-1 722. van Dongen JJ, LangerakAW,BriiggemannM, Evans PA, Hummel M,LavenderFL, Delabesse E, Davi F, SchuuringE, Garcia-SanzR, van KriekenJH, Droese J, Gonzilez D, BastardC, White HE, SpaargarenM, Gonzilez M, ParreiraA, Smth JL, MorganGJ, Kneba M, MacintyreEA (2003): Design and standardizationof PCR primersand protocolsfordetectionof clonal immunoglobulin andT-cell receptorgene recombinationsin suspectI ymphoproliferations:reportof the BIOMED-2 ConcertedAction BMH4-CT98-3936. Leukemia 17:2257-23 17.

372

MATURE B- AND T-CELL NEOPLASMSAND HODGKIN LYMPHOMA

Vater I, WagnerF, Kreuz M, Berger H, Martin-SuberoJI, Pott C, Martinez-ClimentJA, KlapperW, KrauseK, Dyer MJ,Gesk S, HarderL, ZamoA, Dreyling M, HasencleverD, ArnoldN, SiebertR (2008): GeneChipanalysespoint to novel pathogeneticmechanismsin mantlecell lymphoma.Br J Haematol Epub ahead of print. VenturaRA, Martin-SuberoJI, Jones M, McParlandJ, Gesk S, Mason DY, Slebert R (2006): FISH analysis for the detectionof 1ymphoma-associatedchromosomalabnormalitiesin routineparaffinembeddedtissue. J Mol Diagn 8: 141-15 1. ViardotA, MollerP, Hogel J, WernerK, MechtersheimerG, Ho AD, OttG, BarthTF, SiebertR, Gesk S, SchlegelbergerB, DohnerH, Bentz M (2002): Clinicopathologiccorrelationsof genomic gains and losses in follicular lymphoma. J Clin OncoI20:45234530. Virgilio L, NarducciMG, IsobeM, Billips LG, CooperMD, CroceCM,Russo G ( 1994): Identification of the TCLl gene involved in T-cell malignancies. Proc Natl Acad Sci USA 9 I :12530-1 2534. Weber-Matthiesen K, Deerberg J, Poetsch M, Grote W, Schlegelberger B (1995): Numerical chromosome aberrationsare present within the CD30’ Hodgkin and Reed-Stemberg cells in 100%of analyzed cases of Hodgkin’s disease. Blood 86: 1464-1468. WeisenburgerDD, GordonBG, Vose JM, Bast MA, ChanWC, GreinerTC, AndersonJR,SangerWG ( 1996): Occurrenceof the t(2;5)(p23;q35) in non-Hodgkin’slymphoma. Blood 87:3860-3868. Weniger MA, Melzner I, Menz CK, Wegener S, Bucur AJ, Dorsch K, Mattfeldt T, Barth TF, Moller P (2006): Mutations of the tumor suppressor gene SOCS-I in classical Hodgkin lymphoma are frequent and associated with nuclear phospho-STAT5accumulation. Oncogene 25 :2679-2684. Wessendorf S, Barth TF, Viardot A, Mueller A, Kestler HA, KohlhammerH, Lichter P, Bentz M, DohnerH, Moller P, SchwaenenC (2007): Furtherdelineationof chromosomalconsensus regions in primarymediastinalB-cell lymphomas:an analysis of 37 tumorsamples using high-resolution genomic profiling (array-CGH).Leukemiu 2 I :2463-2469. Willis TG, Dyer MJ (2000): The role of immunoglobulintranslocationsin the pathogenesisof B-cell malignancies. Blood 96:808-822. Willis TG, JadayelDM, Du MQ, Peng H, PerryAR, Abdul-RaufM, Price H, KarranL, Majekodunmi 0, WlodarskaI, Pan L, CrookT, HamoudiR, Isaacson PG, Dyer MJ (1999): BcllO is involved in t( I; 14)(p22;q32)of MALTB cell lymphomaandmutatedin multiple tumortypes. Cell 96:3545. Wilson KS, McKennaRW, KroftSH, Dawson DB, AnsariQ, SchneiderNR (2002): Primaryeffusion lymphomas exhibit complex and recurrentcytogenetic abnormalities. Br J Haemafol 116: 1 13-1 2 1. Wlodarska1, Martin-GarciaN, Achten R, De Wolf-PeetersC, Pauwels P, Tulliez M, de MascarelA, BrikreJ, Patey M, HagemeijerA, GaulardP (2002): Fluorescence in situ hybridizationstudy of chromosome 7 aberrationsin hepatosplenic T-cell lymphoma: isochromosome 7q as a common abnormalityaccumulatingin forms with featuresof cytologic progression.Genes Chromosomes Cancer 33:243-25 1. Wlodarska 1, Nooyen P, Maes B, Martin-SuberoJI, Siebert R. Pauwels P, De Wolf-Peeters C, Hagemeijer A (2003): Frequent Occurrenceof BCL6 rearrangementsin nodular lymphocyte predominanceHodgkin lymphomabut not in classical Hodgkin lymphoma.Blood 101:70&710. Wlodarska1, Meeus P, Stul M, ThienpontL, WoutersE, Marcelis L, Demuynck H, RummensJL, Madoe V, Hagemeijer A (2004): Variant t(2;l I)(pll ;q13) associated with the IgK-CCNDI rearrangementis a recurrenttranslocation in leukemic small-cell B-non-Hodgkin lymphoma. Leukemiu 18:1705-1 7 10. Wlodarska I, Veyt E, De Paepe P, VandenbergheP, Nooijen P, Theate I, Michaux L, Sagaert X, MarynenP, HagemeijerA, De Wolf-PeetersC (2005): FOXPI, a gene highly expressed in a subset of diffuse large B-cell lymphoma, is recurrently targeted by genomic aberrations.Leukemiu 19: 1299- 1305.

REFERENCES

373

Wlodarska I, MatthewsC, Veyt E, Pospisilova H, Catherwood MA, Poulsen TS, VanhentenrijkV. lbbotson R, VandenbergheP, MorrisTC. AlexanderHD (2007): TelomericIGH losses detectable by fluorescence in situ hybridization in chronic lymphocytic leukemia reflect somatic VH rccombinationevents. J Mol Diagn 9:47-54. Wolfs. MertensD, SchaffnerC, KorzC, DohnerH,StilgenbauerS, LichterP (2001):B-cell neoplasia associated gene with multiple splicing (BCMS): the candidateB-CLL gene on l3q14 comprises more than 560 kb covering all critical regions. Hum Mol Genet 10 1275-1285. Wolff DJ, Bagg A, Cooley LD, Dewald GW, Hirsch BA, Jacky PB, Rao KW, Rao PN (2007): Guidance for fluorescence in situ hybridizationtesting in hematologic disorders.J Mol Diugn 9: 134-143. Wu KL, Beverloo B, Lokhorst HM. Segeren CM, van der Holt B, SteijaertMM, Westveer PH, Poddighe PJ, Verhoef GE, Sonneveld P, Dutch-Belgian Haemato-OncologyCooperative Study Group (HOVON), Dutch Working Party on Cancer Genetics, Cytogenetics (NWCGC) (2007): Abnormalitiesof chromosome Ip/q are highly associated with chromosome 13/13q deletions and are an adverse prognostic factor for the outcome of high-dose chemotherapy in patients with multiple myeloma. Br J Haemarol 136:615-623. Ye BH, ListaF, Lo COCO F, Knowles DM, Offit K, ChagantiRS. Dalla-FaveraR (1993a):Alterationsof a zinc finger-encodinggene, BCL-6, in diffuse large-cell lymphoma. Science 262:747-750. Ye BH. Rao PH, Chaganti RS, Dalla-FaveraR (3993b): Cloning of bcl-6, the locus involved in chromosometranslocationsaffecting band3q27 in B-cell lymphoma.Cancer Res 53: 2732-2735. Ye H, Gong L, Liu H, HamoudiRA, Shirali S, Ho L, Chott A, Streubel B, SiebertR, Gesk S, MartinSubero J1, Radford JA, Banerjee s, Nicholson AG, Ranaldi R, Remstein ED, Gao Z, Zheng J, IsaacsonPG. Dogan A, Du MQ (2005):MALTlymphomawith t( 14;18)(q32;q21 )/IGH-MALT1is characterizedby strong cytoplasmic MALT1 and BCLlO expression. J Pathol205:293-301. Ye H, Gong L, Liu H. Ruskone-FourmestrauxA. de Jong D, Pileri S, Thiede C, LavergneA, Boot H, Caletti G, Wundisch T,Molina T,Tad BG, Elena S , NeubauerA, Maclennan KA, Siebert R, RemsteinED, Dogan A, Du MQ(2006):StrongBCLlOnuclearexpressionidentifiesgastricMALT lymphomas that do not respond to H . pylori eradication. Guf 55: 137-138. YoshidaS, NakazawaN, lida S. Hayami Y, Sat0 S, WakitaA, Shimizu S. TaniwakiM, Ueda R (1999): Detection of MUMMRF4-1gH fusion in multiple myeloma. Leukemia 13:I8 12- I8 16. Yunis JJ, Oken MM, Theologides A, Howe RB, KaplanME (1984): Recurrentchromosomaldefects are found in most patients with non-Hodgkin’s-lymphoma.Cancer Genet Cytogenef 13:17-28. Zandecki M, Facon T, PreudhommeC, VanrumbekeM, Vachee A, Quesnel B, Lai JL, Cosson A, FenauxP ( 1995): The retinoblastomagene (RB- 1) statusin multiplemyeloma:a reporton 35 cases. Leuk Lymphoma l8:497-503. Zandecki M, Lai’ JL, Facon T (1996): Multiple myeloma: almost all patients are cytogenetically abnormal.Br J Haematol94:217-227. Zani VJ, Asou N, Jadayel D, HewardJM, Shipley J, Nacheva E, TakasukiK, Catovsky D, Dyer MJ (1996): Molecularcloning of complex chromosomaltranslocationt(8; 14;12)(q24.I ;q32.3;q24.1) in a Burkittlymphomacell line defines a new gene (BCL7A) with homology to caldesmon.Bfood 8 7 3 124-3 134. Zech L, HaglundU, Nilsson K, Klein G ( 1976):Characteristicchromosomalabnormalitiesin biopsies and lymphoid-cell lines from patients with Burkitt and non-Burkittlymphomas. In/ J Cancer 17~47-56. Zech L, HammarstromL, Smith CI (1983): Chromosomalaberrationsin a case of T-cell CLL with concomitant IgA myeloma. Inr J Canwr 32:431-435. Zettl A. Ott G, Makulik A, KatzenbergerT, Starostik P, Eichler T, Puppe B, Bentz M, MiillerHermelink HK, Chott A (2002): Chromosomalgains at 9q characterizeenteropathy-typeT-cell lymphoma.Am J Puthol 161:1635-1645.

374

MATURE 6-AND T-CELL NEOPLASMS AND HODGKIN LYMPHOMA

Zettl A, RiidigerT,KonradMA, ChottA, Simonitsch-KluppI, Sonnen R, Miiller-HermelinkHK, Ott G (2004): Genomic profiling of peripheralT-cell lymphoma, unspecified, and anaplastic large T-celllymphomadelineatesnovel recurrentchromosomalalterations.Am J Pathol164:1837-1848. Zhan F,RardinJ, KordsmeierB, BummK, ZhengM, TianE, SandersonR, YangY,Wilson C, Zangari M, Anaissie E, Moms C, Muwalla F, van Rhee F, Fassas A, Crowley J, Tricot G, Barlogie B, Shaughnessy J Jr (2002): Global gene expression profiling of multiple myeloma, monoclonal gammopathy of undetermined significance, and normal bone marrow plasma cells. Blood 99:1745-L757. Zhang S, Zech L, Klein G (1982): High-resolution analysis of chromosome markersin Burkitt lymphomacell lines. Int J Cancer 29: 153-1 57. Zhang Q, Siebert R, Yan M, HinzmannB, Cui X, Xue L, RakestrawKM,Naeve CW,BeckmannG, WeisenburgerDD, Sanger WG, Nowotny H, Vesely M, Callet-Bauchu E, Salles G, Dixit VM, Rosenthal A, SchlegelbergerB, Moms SW (1999): Inactivatingmutationsand overexpressionof BCL10, a caspase recruitmentdomain-containinggene, in MALT lymphoma with t(1; 14)(p22; q32). Nut Genet 2263-68. ZhouY,Ye H,Martin-SuberoJ1, HamoudiR. Lu YJ,WangR, SiebertR, Shipley J, IsaacsonPG,Dogan A. Du MQ (2006): Distinct comparative genomic hybridisation profiles in gastric rnucosaassociated lymphoid tissue lymphomas with and without t( 1 1; 18)(q2 1 ;92 1). Br J Huernatol 133:3542. Zhou Y, Ye H, Martin-SubemJI, Gesk S. HamoudiR, Lu YJ, Wang R, Shipley J, Siebert R, isaacson PG, Dogan A, Du MQ (2007): The patternof genomic gains in salivarygland MALTlymphomas. Haernaiologica 92921-927. Zinkel S, Gross A, Yang E (2006): BCL2 family in DNA damage and cell cycle control. Cell Death D.@Y 13:135 1-1359.

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CHAPTER 11

Tumors of the Upper Aerodigestive Tract MIHAELAAVRAMUTand SUSANNE M. GOLLIN

Upper aerodigestive tract cancer includes tumors of the head and neck (oral cavity, oropharynx,pharynx, hypopharynx,and larynx), nasal cavity, sinuses, nasopharynx, salivary glands, and esophagus.In this chapter,we discuss the cytogenetic alterationsin these tumorsas well as their molecularcorrelatesand prognosticimplications.

SQUAMOUS CELL CARCINOMAS OF THE HEAD AND NECK Cytogenetic Findings Squamouscell carcinomasof the head and neck (SCCHN)are the most importanttumors of'the upperaerodigestivetract and rank as the eighth most common cancer worldwide. They comprise 3% of new cancers and account for 2% of cancer deaths annuallyin the United States(Jemalet al., 2007). If identifiedearly,the prognosisof SCCHNis excellent. However,over the past 40 years,SCCHNsurvivalin Caucasianshas only improvedslightly and in AfricanAmericans,the survivalratehas decreased(Parkinet al., 2005). One-,five-, and ten-year relative survival rates for oropharyngealcancer are 84, 60, and 48%, respectively (Parkinet al., 2005). One-fourthof SCCHN worldwideare associated with human papillomavirus(HPV) infection,most frequentlyHPV16 (D'Souza et al., 2007). HPV-relatedSCCHNgenerally have fewer genetic alterationsthan otherSCCHN;patientswith HPV-positiveoropharyngeal tumors have better disease-free and overall survival than those with HPV-negative tumors(Raginet al., 2006; RaginandTaioli,2007). Therefore,it is essentialto test SCCHN for HPV to fully integrateall prognosticfactors.Hopefully,the frequencyof HPV-related SCCHN will decrease significantly with the implementationof prophylacticvaccination against the majoroncogenic types of the virus. Cytogeneticanalyseshavebeen reportedfor over300 SCCHN,of which nearly200 were oral (includingtongue), over 100 were laryngeal,and 50 were oropharyngealand hypopharyngeal(Mitelmanet al., 2008). In general,SCCHNhave largely similarchromosomal alterationsirrespectiveof their exact site, suggesting that they develop via common pathogeneticpathways(Jin et al., 2006b). Cuncer Cyfogmetics. Third Edition, edited by Sverre Heim and Felix Mitelman Copyright Q 2009 John Wiley & Sons, Inc.

375

376

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Likeothertumors,SCCHNdevelopas a resultof dysregulationof multiplecancer-related genes, that is, oncogenes, tumor suppressorgenes (TSG), and genome integrity genes. A geneticprogressionmodelfor SCCHNhas been proposed(Califanoet al., 1996;Forastiere et al., 2001) based on the conceptthattumors developand progressas a resultof an orderly accumulationof chromosomaldeletions(with concomitantTSG losses) and rearrangements and/oramplifications(withassociatedoncogene activations)that imbuea clonal population of cells with a proliferativeadvantage.Califanoet al. (1996), using microsatelliteanalysis to test for allelic loss at 10 loci, foundthatadjacenttumorareaswith differenthistopathological appearancessharedcommon genetic changes,but the spectrumof chromosomalloss progressivelyincreasedat each histopathologicalstep from benign hyperplasiato invasive cancer.They also found that abnormalmucosal cells surroundingtumorssharedcommon geneticalterationswith those lesions andthusappearedto arisefroma singleprogenitorcell. A more recent multistepprogressionmodel of oral SCC was based on analysisof genetic alterationsby comparativegenomic hybridization(CGH) in primarytumorsand adjacent dysplasticlesionsfromthe samebiopsy specimen(Noutomiet al., 2006). The resultsshowed thatgainsof 3q26-qter.5pl5. 8qI 1-21, and8q24.1-qterandloss of 1 8q22-qterwereinvolved in thetransitionfrommild to moderatedysplasia.Gainsof 1Iq 13,14q, 17qI 1-22, and2Oq and loss of 9p were involved in the transitionfrom moderateto severe dysplasia. Losses of 3~14-23 and 5q12-22 were frequentlyseen togetherand were associatedwith progression from severe dysplasiato invasive cancer.Loss of 4p was linked to lymph node metastasisin patientswith oralSCC. Wreesmannet al. (2004) showed thatseveralcytogeneticalterations identifiedby CGHin nodalmetastaseswerenot presentin the primarytumors,includinggains of 1Op11-1 2 and 1 I p andlosses of 4q22-3 1,9p13-24, and 1%. Genesthatmay be targetedby these imbalancesareinvolvedin cell adhesionand/orin the mitogen-activatedproteinkinase (MAPK) and phosphatidylinositol3-kinase (PI3K) pathways. Califanoet al. (1996,2000b) and Braakhuiset al. (2004) proposedthatthesemolecular geneticfindingssupport“field cancerization.”This concept,firstput forwardby Slaughter et al. ( I 953), involves the exposureof epithelialtissue to carcinogenicor cancer-promoting substances,such as cigarettesmoke, alcohol, and/orviruses.Neoplasia occursfirst where the exposure is maximal, but all exposed tissues have the opportunityto express the neoplastic phenotype.Multiple regions of premalignantchange may coalesce to form a largelesion ormulticentricfoci. Thegeneticchangesin SCCHNmay be conceptualizedas a seriesof evolutionaryevents thatmay have neutral,deleterious,or advantageouseffects on the proliferationof a clone or clones of cells. Neutralor deleteriousgenetic changesmay resultin stagnationor cell death,whereasadvantageouseventsmay resultin a proliferative advantage,an increasein recruitmentof blood vessels to the developingtumor,and/orthe abilityto metastasize.Themodelof Braakhuiset al. (2004) advancedthisideaby suggesting that the initialgenetic alterationoccurs in a stem cell, formingfirst a patch and then an expandingfield of cells with the original and subsequentgenomic and/orchromosomal alterations.Then,clonalselectionof one ormorecells withinthis field of preneoplasticcells leads to the developmentof a carcinoma(s).Harperet al. (2007) showed that a small percentageof culturedSCCHNcells meet the criteriafor cancer “stemcells,” thatis, they have the capacityfor self-renewal,to generatean amplificationhierarchy,and to produce cells thatdifferentiateappropriately.Metastasesmay be derivedfrom migratingstem cells from the originalfield or tumor,and second primariesmay develop from newly deranged stem cells (Braakhuiset al., 2004). Cytogeneticabnormalitieshave been shown to be useful biomarkersfor diagnosisand prognosis of malignancies and point to locations of specific genes where molecular

SQUAMOUS CELL CARCINOMAS OF THE HEAD AND NECK

377

disruptionshave occurred.Karyotypesare usuallypreparedfromanalysisof short-or longterm SCCHN cell cultures,since mitoses are usually not observedafterdirectharvestof dissociatedtumorbiopsies. Critics may arguethatcytogenetic analysis of cell culturesis inherentlybiased, since specific cell populationsare selected for and evolve in culture.To the contrary,Worshamet al. (1999) and Martinet al. (2008) utilized fluorescencein situ hybridization(FISH)to show thatthe cytogeneticalterationsobservedin metaphasesfrom long-termSCCHNcell culturesreflect aberrationspresentin interphasecells from either directharvestsof biopsies, touch preparations,or paraffinsections of the primarytumors fromwhich they were derived.Further,Reshmiet al. (2004) showedthatthe karyotypesof SCCHNcell lines arerelativelystableover time. Albertsonet al. (2003) providedevidence that clonal chromosomalalterationsin tumorsmay confer a selective growth advantage, leadingto chromosomalstability.These studiesall arguein favorof the valueof examining short-or long-termculturedSCCHNcells or cell lines. The karyotypes of SCCHN (reviewed by Gollin, 2001; Jin et al., 2006b; Martin et al., 2008) typically are complex, often near-triploid,and contain multiple clonal numericalandstructuralchromosomeabnormalities(Fig. I I.I ). Oftenthereis considerable cytogeneticvariabilityamongcells, reflectingheterogeneitydue to clonal evolutionwithin the originaltumor,as shown by Worshamet al. (1999) and Martinet al. (2008). The cellto-cell differencesare due in partto cytoskeletalalterations,which result in chromosomal segregationaldefects and lead to karyotypicdifferences between daughtercells after mitosis, that is, chromosomalinstability (Saunderset al., 2000; Gollin, 2005). These spindle defects may be the result of chromosomalaberrations.One example is the amplification and consequentoverexpressionof the NUMAl gene at I lq13, which results in multipolarspindles, leadingto daughtercells that differ from each otherand theirmother cell (Saunderset al., 2000; Huanget al., 2002; Quintyneet al., 2005).

1

2

7

6

13

8

4

3

9

5

12

10

18

14

LO

z

20 21 22 X Y FIGURE 1 1.1 Representative trypsin-Giemsa banded karyotype from a squamous cell carcinoma cell line (UPCI:SCC131, passage 18). In this cell, there are two relatively normal-appearing chromosomes I 1 on the left and two very long derivative chromosomes I 1, each with an hsr at 1 1 q 13 and non-chromosome I I derived chromatin distal to the hsr, with a deletion of 1 1q I 4 to 1 1qter. 19

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TUMORS OF THE UPPER AERODIGESTIVE TRACT

Chromosomalgains andlosses in SCCHNhave been identifiedby chromosomebanding analysis as well as by molecularcytogenetic techniques. The findingsby bandinghave been refinedin some cases using multicolorFISH (M-FISH)or spectralkaryotyping(SKY). In addition,chromosomaland/orarrayCGH(cCGH,aCGH)hasbeen utilizedto clarifythe copy numbersof chromosomesin cell lines andto determinethe “molecularkaryotypes”of tumorsrefractoryto karyotypingbecausethey were paraffin-embedded,frozen,or did not expresssufficientmetaphasecells. The frequencyof chromosomallosses appearsto exceed thatof gains (Jinet al., 2006b;Martinetal., 2008). Althoughnot discussedfrequentlyin the literature,the most commonkaryotypicchange in SCCHNis tetraploidization(Shackney et al., 1989), and frequentlySCCHN cell cultures express both near-diploidand neartetraploidsubclones(Martinet al., 2008). The timingof tetraploidizationin SCCHNhas not been characterizedfully, althoughit appearsto occurafter1 lq13 amplification.Supportfor this notion comes from the observationthat most of the cells with I lq 13 amplification exhibit four copies of chromosome 1 1 , two of which contain homogeneously staining regions (hsr) and two of which appearto be normal (Martinet al., 2008). Structuralchromosomealterationsare common in SCCHN,includingdeletions,translocations, isochromosomes, and unidentified marker chromosomes. Duplications, insertions, inversions, ring chromosomes,dicentric chromosomes,and endoreduplicated chromosomeshave also been reported,butless frequentlythanthoselisted above.Evidence of gene amplificationin the formof an hsris oftenpresent(Albertson,2006) whereasdouble minute (dmin)chromosomesare much less common. Although some investigatorshave attemptedto identifythe one gene “driving”gene amplification,multiplegenes within an amplified segment (amplicon) are overexpressed,suggesting that gain or amplification of chromosomalsegmentsis drivenby more than one gene (Huanget al., 2006). Ln spite of the numerous diversestructuralabnormalities,cytogenetic analyses of SCCHN have revealedseveralconsistentchromosomalbreakpoints,includingbands I pl3 and I 1q 1 3 (Jin et al., 1990, 1998b, 1 9 9 8 2006b ~ &emall et al., 1997). Structuralchromosomerearrangements involving the cleavage and fusion of centromeresfrom both participatingchromosomes areamongthe most frequentlyobservedalterations(Hermsenet al., 2005) and result in whole-armtranslocations,includingRobertsoniantranslocationsbetween two acrocentric chromosomesor formationof isochromosomes,particularlyfor 3q, 5p, 7p, 8q, and9q. Formationof these isochromosomesresultsin loss of the otherchromosomearm,contributing to the frequentobservationof loss of chromosomearms 3p, 8p, and 9p in SCCHN (Gollin. 200 I ;Hermsenet al., 2005; Jin et al.. 2006b;Martinet al., 2008). The mechanism by which these whole-armtranslocationsoccurs is not entirelyclear,but severalplausible hypotheseshave been proposed,includingloss of function of topoisomeraseIIb, which maps to 3p (see 3p Loss section; Hermsen el al., 2005). Numerous other nonrandom chromosomeabnormalitieshave been observed by banding and molecularcytogenetic analysisof multipleindependenttumorsfrom previouslyuntreatedpatients.In describing primarycytogeneticabnormalitiesin humantumorsor the correlatesbetweenchromosome alterationsand tumor behavior, it is importantto analyze only tumors from patients previouslyuntreatedby chemotherapyor radiation,because these modalitiesmay lead to chromosomeaberrationsthatmaycorrupttheresultsof the study.Ontheotherhand,one can monitorkaryotypicevolution in a tumorover time and identifythe cytogeneticalterations that evolve during therapyor as a result of tumorprogression,and delineate prognostic markersthat may change over time in a tumoror its local or distant metastases.These cytogenetic findings (whetheridentified by classical or molecularcytogenetic methods, includingFISH,cCGH,or aCGH)may be useful in specifyingtherapyeffect or prognosis.

SQUAMOUS CELLCARCINOMASOF THE HEAD AND NECK

379

The most frequentchromosomalgain in SCCHNis thatof distal3q andthe most frequent segmental loss is of 3p. In many cases, these findings result from formation of an isochromosomefor 3q, leading to duplicationof the long arm and loss of the shortarm. In contrast,the majorityof extracopies of 3q observedin our SCCHN cell lines resulted fromunbalancedtranslocations(Martinet al., 2008). Likewise, somecases of 3p loss appear to be due to breakageat 3~34.2,the site of the most common chromosomalfragile site, FRA3B, and the FHZT gene (Ishii et al., 2006; Durkinand Glover, 2007). The next most commongains are of chromosomearms5p, 7p, 8q, and 9q, again frequentlyas a resultof isochromosomeformation,along with concomitantlosses of the short arms of chromosomes 8 and9 and the long armsof chromosomes5 and 7. As mentionedearlier,band 1 1q 1 3 appearsto be amplified (usuallyin the form of an hsr) or duplicatedin almost half of all SCCHNanalyzed(reviewedby Gollin, 2001; Huanget al., 2002, 2006; Jin et al., 2006a). Thatamplificationof 1 1q13 occursby breakage-fusion-bridge (BFB) cycles was recently confirmed(Reshmiet al., 2007b), which led to FISH studiesshowing distal I lq loss (1 Iq 14-qter)in as many as 70% of SCCHN,thusrevealingone of the most commonregionsof loss in thesetumors(Parikhet al., 2007). Gainandoccasionalamplificationof band20q13.2 arealso commonin SCCHNas well as othertumors(Sparanoet al., 2006; Guanet al., 2007). The most frequentchromosomallosses appearto involve eithercommonchromosomal fragile sites (FRA3B at 3p14 and FRAlfF at 1 lq14.3) or breakageand rearrangement of centromeres,resultingin isochromosomeformationfor,in particular,3p, 5q, 7q, 8p, and9p. The next most frequentlosses involve the long armsof the acrocentricchromosomes13 and 21, the long arms of chromosomes4 and 18, and the sex chromosomes.Van Dyke et al. (1994) observedthatthe Y chromosomeis lost frequentlyin males as is the inactiveX chromosome,particularlyXp, in females.Additional,less commonchromosomallosses are noted in Table 1 1.1. Of interestis the observationthatseveralof the geneticchanges(17p I3 loss, 14q24 loss, and 6p loss) discovered by moleculargenetic methodsand noted to be importantin the progressionof SCCHN,were not observedat a high frequencyby classical or molecular(CGH)cytogeneticmethods.Oneplausibleexplanationforthisdiscrepancyis that the moleculardeletions may be smallerthan the level of resolution of cytogenetic methodsand, thus, they are not detectable. In summary,the most frequentcytogeneticalterationsin SCCHN are gains of 3q, 5p, 7p, 8q, 9q, 1 lq13, and 20q and losses of 3p, 5q, 8p, 9p, I Iq, 13q, 18q, and 21q. The chromosomalfindingsoften providean explanationfor the moleculargenetic alterations. For example, allelic imbalanceat the CCNDl locus in 1 lq13 could be mistakenas loss of heterozygosity (LOH) when it is actually FISH analysis-confirmedgene amplification (Califanoet al., 1996). Geneticanalysisrevealedthatmost instancesof I I q 13 amplification occur by breakage-fusion-bridgecycles (Reshmiet al., 2007b) and/orduplicon-mediated rearrangement (Gibcuset al., 2007a). As mentionedearlier,cytogeneticobservationsalso suggest that,in manycases, the coordinategainsandlosses involvingarmsof chromosomes 3,5.7,8, and 9 occuras a consequenceof isochromosomeformation.These resultssuggest thatcytogeneticanalysisis valuablefor placingmoleculargeneticfindingsin perspectiveat the cellular level.

Molecular Genetic Correlates of the Key Cytogenetic Findings in SCCHN and Their Prognostic Significance A numberof excellent chromosomebanding and molecularcytogenetic analyses have

been carriedout since the previouseditionof this book. Those publishedbefore 2001 are

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TUMORS OF THE UPPER AERODIGESTIVE TRACT

TABLE 11.1 Meta-Analysisof ChromosomalGainsand Losses in SCCHN" Chromosomal Gains

Frequency by CC

Frequency by CGH

Chromosomal Frequency Losses by CC

Frequency by CGH

1q25-44 3q I 1-qter; srg:3q2&27 5p 14-1 5.3; srg: 5p15 6q22-qter 7pll-22 7q21.2

35/171, 21% 8/30, 27% XP 47/187, 25% 109/163,67% Y

27/46, 59% 17/33, 52%

5/17. 29%

27/17]. 16% 5311 10,48%

2q

38/15], 25%

25/81, 31%

91136, 7% 5/22, 23% 48/171, 28% 54/184, 29% 25/136, 18% 13/41, 32%

3p I 2-24 q23-31 5ql2-23; srl: 5q21

92/187,49% 48/167, 29% 36/172, 21 %

1051175, 60% 27/59, 46% 58/94,62%

8ql3-24.3; srg: 8q24 9q; srg:9q34 I lq13

5 4 1 87.29%

ss

44/17 I, 26%

52/169, 31%

27/142, 19% 40/82,49% 47/171, 28% 92/290, 32%

37/142, 26% 104/204,51%

9/41, 22% 58/123, 47%

17qll-22 1% 20q 12- 13.2

13/136, 10% 101136. 8% 15/45, 33%

7q22-qter 8pter-p21; srl :8p23.2 9p21-24 I Oq22-26 1 1q 14-qter 13q 12-34 14q 17P 1%

55/186, 30% 38/15], 25% 36/136, 27% 48/171, 28% 36/142, 25% 37/161, 23% 77/187, 41%

70/116, 60% 20/67, 30% 49/16], 30% 56/106, 53% 17/124, 14% 6/74,8% 661112, 59%

srl:18q21-23 21ql1.2-21 22

66/180, 37% 44/142, 31 %

46/67, 69% 8/40, 20%

811163, 50%

18/71, 25% 11/46. 24% 15/31, 48%

~~

CC, classical cytogenetic analysis; CGH, comparative genomic hybridization; srg, smallest region of gain; srl, smallest region oi loss. "Frequenciessummed and recalculated from reports in the literature (Cowan, 1992; Patel el al., 1993; Sreekantaiah et al., 1994; Van Dyke et al., 1994; Brzoska et al., 1995; Speicher et al., 1995; Hermsen et al., 1997; Mertens et al., 1997; Bockmuhl et al.. 1998; Webex et al., 1998; Wolff el al.. 1998; Squire et al., 2002 Baldwin et al.. 2005; Snijders et al., 2005; Jin et al., 2006b; Noutomi et al., 2006; Uchida et al.. 2006; Freier et al., 2007; Martins et al., 2007). Data were included only when reported clearly in the text, tables, or figures.

generallycited in Gollin (2001). It is impossiblenot only to discussall the resultsof each individualstudy in this chapter,but even to cite all those thatmight have meritedcitation. A numberof correlatedcytogenetic-moleculargenetic findings have been reportedthat could not be readilyplacedinto the categoriesof individualchromosomesegmentsadhered to below. One exampleis thatof Snijderset al. (2005), who reportedthatTP53 mutationis positively correlatedwith amplificationof CCNDl and EGFR.Indeed,it has become clear thatTP53playsa role in chromosomalstability,andmutationsin TP53 arecommon,seen in abouthalf of SCCHN,andassociatedwith decreasedsurvival(Poetaet al., 2007). It follows that chromosomalinstability,which arises via multiplemechanisms,is one of the most dramaticand prevalentfindingsin SCCHN(Gollin, 2005).

3q Gain Gain of the long armof chromosome3 appearsto be one of the most frequent genetic alterationsin SCCHN, with a smallest region of gain correspondingto bands 3q26-27. Gainsof 3q25-29 have been associatedwith shorteneddisease-specificsurvival (Stichtet al., 2005). Multiplegenes in the region have been examinedto determinewhich is

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most important.AlthoughTP63, CCNLI, DCUNIDl/SCCRO, and PIK3CA are all gained in SCCHN, recentmatrix-CCHdatashow thatPIK3CA undergoescopy numberincrease most frequently(Freieret al., 2007). This oncogene maps to 3q26.3 and codes for the catalyticsubunitof PT3K, a proteincomplex activatedby growthfactortyrosine kinases. growth, The gene productstimulatesAKT signaling,allowing growthfactor-independent cell invasion,and metastasis(Samuelsand Ericson,2006). PtK3CA has been thoughtto be involvedin early SCCHNbecauseamplificationof this gene was observedin precancerous oral dysplasia(Redon et al., 2002). DCUNIDI/SCCRO also maps to 3q26.3, is amplified and overexpressedin SCCHN, and alterationscorrelate with poor clinical outcome (Sarkariaet al., 2006). Singh and colleagues have shown that DCUNIDIISCCRO has oncogenicactivity,at least partof which resultsfromactivationof the hedgehog-signaling pathway(Sarkariaet al., 2006). DCUNIDI/SCCRO knockdownby RNA interferenceand antisense resulted in apoptosis (Sarkariaet al., 2006). Cyclin L1 (CCNLI, 3q25.32) is thoughtto be involved as an immediate-earlygene aftergrowth factorsignaling, in premRNA processing,GOto G 1 cell cycle signaling,and is localized to nuclearspeckles(Sticht et al., 2005). CCNLl hasbeen shownto be amplifiedandoverexpressedin tumorscompared to correspondingnormaltissues(Redonet al., 2002; Mulleret al., 2006), is associatedwith lymph node metastases independentof anatomic site and T-stage, and also with more advancedclinical stage (Stichtet al., 2005; Mulleret al., 2006). High-level amplificationis associatedwith shorteroverallsurvivalin SCCHNfromall sites except the pharynx(Sticht et al., 2005; Mulleret a]., 2006). The TP63 gene @4O/p73UAIS) mapsto 3q28, shows copy numbergains, and is overexpressedin SCCHN(Stichtet al., 2005). Lo Muzio et al. (2007) showed by immunohistochemistrythat TP63 protein overexpressioncorrelatedwith a worse survivalratein oral SCCpatients.Hibi et al. (2000) observedthatoverexpressionof Trp63in Rat 1a cells leadsto a transformedphenotype.Thus,TP63 appearsto play a role in carcinogenesisandmay be involvedin positive selection for this segmentalgain in SCCHN and othertumors,althoughit mapsdistalto the smallestregionof gain. Recent studieshave shownthatoverexpressionof the ATR gene at 3q22-24 couldresultin tumorinitiationa n d or progressionby promotingchromosomalinstabilitythroughan aberrantDNA damage response(Smithet al., 1998;Collin, 2005; Parikhet al., 2007). Additionalcandidategenes at 3q25-27 that are amplified and overexpressed in SCCHN include TIPARP, TERC, EIF4G1, and DVL3 (reviewed by Wreesmannand Singh, 2005). An integratedcopy number-geneexpressionmicroarrayanalysis of laryngealSCC by Jarvinenet al. (2006) showed overexpressionof additionalgenes associatedwith 3q gain includingRAB6B at 3q22, PDCIO, and GPCRl at 3q26, MCCCI, and LAMP3 at 3q27, and TRFC at 3q29. Snijderset al. (2005) reportedamplificationof TM4SFI at 3q24-25 in oral SCC. The observationsthat copy numbergains andloroverexpressionof multiplegenes on distal 3q were associated with tumor progression.and an aggressive clinical course in SCCHN, suggestthatmultiplegenes may be involvedand thatone or moreof thesegeneslproteins,or the biochemical pathways in which they participate,may be targets for therapeutic intervention.

7p Gain Copy number increases of 7p12-22 have been observed in nearly 30% of SCCHN cell lines by classical cytogeneticsand CGH (Table 1 I . I ; Collin, 2001; Martin et al., 2008). Merrittet al. (1 990) first showed amplificationand overexpressionof the epidermalgrowth factor gene (EGFR, 7pl2) in SCCHN. Subsequentstudies by Rubin Grandiset al. (1998) demonstratedthatincreasedproteinexpressionof EGFRandits ligand, TGF-a, are significantpredictorsfor disease recurrenceand decreasedoverall survival,

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which suggested that EGFR is an importantoncogene in a subset of SCCHN.We now know that EGFR is overexpressedin as many as 90% of SCCHN (Kalyankrishnaand Grandis,2006). Overexpressionof EGFR in SCCHN contributesto an aggressive and treatment-resistant phenotypewith a poorprognosisandarisesas a resultof severaldifferent mechanisms.A frequentcause is increasedEGFR gene copy number,includingsome cases of gene amplificationand others of polysomy 7. Additionalcauses include increased mRNA synthesis,decreaseddownregulation,andexpressionof EGFRvIII,a constitutively activetruncatedform of the proteinseen in almost half of SCCHN.EGFRplays key roles in SCCHN growth, survival,invasion, metastasis,and angiogenesis(Kalyankrishnaand Grandis,2006). A recentFISHanalysisof EGFR copy numbershowedthat58%of SCCHN with high polysomy and/or gene amplificationhad a statistically significant shorter progression-freeand overall survival (Chung et al., 2006). Although FISH remains the gold standardfor copy numberassessment, a recent study used quantitativereal-time polymerasechainreaction(Q-PCR)to reveal alteredcopy numberin 24% of tumors,17% with increasedcopy numberand 7%with decreasedcopy number(Temamet al., 2007). The resultsshowedthatpatientswhose tumorshad EGFR copy numberalterations,had poorer overall,cancer-specific,and disease-freesurvivalcomparedto patientswith normalcopy numbers(n = I34,p < 0.0001).The 5-yearsurvivalfor patientswith increasedEGFR copy numberwas 9%comparedto 7 1 % for patientswith normalcopy numbers.Thesestudiesall tested for mutationsin EGFR exons 18, 19, and 21, since these correlatewith sensitivityto the tyrosinekinaseinhibitors,erlotinibandgefitinib,in lung cancer,but none weredetected in any of the three studies. Furthercorrelationswith outcome after combined therapy using EGFRinhibitorsmay reveal a clinical applicationfor FISHas a useful biomarkerin SCCHN.

89 Gain Gain of 8q was identifiedin 45%of SCCHNand cell lines by cCGH (Squire et al., 2002). Agochiya et al. (1999) used FTSH to showMYC andPTK2 (8q24)copy number gain or amplificationin several primarytumortypes, includingSCCHN.FISH confirmed the cytogeneticresultsof a numberof groupscited in this chapterby showingthatthe 8q copy numberincreaseis frequentlydue to isochromosomeformation.Further,Agochiya et al. (1 999) observedthatincreasedPTK2 gene dosage is associatedwith increasedgene expressionin most cell lines, althoughcoordinateincreasein MYC proteinexpressionwas not alwayspresent.TheseinvestigatorsthereforesuggestedthatthePTK2 gene, whichplays an importantrole in adhesion and growth-regulatorysignal transduction,might provide selectionpressurefor maintainingincreasedgene dosage at distal8q. Jarvinenet al. (2006) identifiedthreeadditionalgenes at 8q24 both gained and overexpressedin laryngealSCC, namely, SL4, WISPI, and NDRGI. 7 7973 Amplification Band I lq13, which harborsthe locus for the cyclin D1 gene (CCNDZ), is amplifiedin the formof an hsr in 30-50% of SCCHNandto a lesserdegreein a number of other carcinomas.This amplification is best visualized with FISH. Izzo et al. (1998) found 1 lq13 amplificationto be an early change in SCCHN, and Noutomi et al. (2006) concluded that it played a role in the transitionfrom moderateto severe dysplasia.We have shown in the majorityof oral SCC cell lines that I lq 13 amplification occurs as a resultof BFB cycles initiatedby a breakat the common chromosomalfragile site FRAIlF (Shusteret al., 2000; Reshmi et al., 2007a, 2007b), consistent with other studieswhich have demonstratedthatgene amplificationmay result From the breakageat chromosomalfragile sites (Ciullo et al., 2002; Hellmanet al., 2002). Commonfragilesites

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arethoughtto lead to difficultiesduringDNA replication,and when underreplicationstress as a resultof carcinogenexposureor conditionsthatoccurin precancerouslesions or cancer cells, may lead to replicationfork stall or collapse, cell cycle checkpointinduction,and DNA repair(DurkinandGlover,2007). In oralSCC,defectsin theDNA damageresponseas a resultof genetic loss distalto the I Iql3 ampliconanddouble-strandbreakageat FRAl I F as a resultof replicationfork collapse, may promptaberrantDNA repairto occurthrough sister chromatidfusion, leading to chromosomalinstabilitythroughBFI3 cycles (Shuster et al., 2000; Reshmiet al., 2007a, 2007b). Alternatively,Gibcuset al. (2007a)proposedthat these 1 1 q I3 fragilesites arenot involvedin the breakagenecessaryfor I 1q13 amplification, butthatthe presenceof both syntenictransitionsand segmentalduplicationsdeterminethe patternof amplificationaccordingto the model proposedby Narayananet al. (2006). The core of the llq13 amplicon contains 13 genes (Huang et al., 2002, 2006; Jin et al., 2006a), including CCNDI, CTTN/EMSl, FGF3/IN72, FGF4/HSTF1, FADD, TAOS//ORAOVI, and TAOS2ITMEM16A. Since the RNA transcriptand CCNDI protein have been found overexpressedin oral SCC cells, it is thoughtto play an importantrole in SCCHNprogression.In addition,rapiddiseaserecurrenceandpoorsurvivalin cases with lymph node involvement have been shown to correlatewith cyclin D1 protein overexpression (Jareset al., 1994; Michalideset al., 1995, 1997; Fracchiollaet al., 1997). Freieret al. (2006) noted that several cytoskeleton-associatedgenes are co-amplified at 1 1q 13,a pointalso discussedby Huanget al. (2006), suggestingthatthesegenes may play a role in motility and invasiveness.Cortactinoverexpressionby immunohistochemistry has been correlatedwith lymph node metastasis(Rothschildet al., 2006). These investigators also used RNA interferenceto show thatdownregulationof Ci'TN in amplifiedcells impairs cell motility and invasion. Recent results by Gibcus et al. (2007b) indicate that FADD is amplified and overexpressedin laryngealcarcinomas,andthey proposedthattumorswith high levels of SerIg4 phosphorylatedFADD may respondto Taxol-basedcombined chemotherapyand radiotherapy. Rothschild et al. (2006) and Timpson et al. (2007) found that SCCHN that overexpresscortactin(C77"EMSI) are resistantto the EGFR kinase inhibitorgefitinib andsuggestedC77'iVas a possiblemarkerof prognosis,diseaseprogression,andtherapeutic responsiveness,especially to EGFR-directedagents. They indicatedthat this might be relatedto the modest therapeuticsuccess of this targetedinhibitorin SCCHN. Ourmore recentresults,confirmedby those of Gibcuset al. (2007b),have shownthatall but 4 of I3 genes in the 1 I q 13 ampliconcore are overexpressedin what appearsto be a coordinatedmanner(Huanget al., 2006). We proposedthat 1Iq 13 amplificationis driven by a cassette of genes thatprovidegrowthor metastaticadvantageto cancercells. Martin et al. (2008) showed in our series of oral SCC cell lines that all of those with llq13 amplificationalso showeddistal 1Iq !ass. Statisticalanalysesrevealedthatamplificationof 1 1 q 13,identifiedby thepresenceof an hsr,andconcomitantdistal 1 1q loss were statistically associated with tumorsite (p= 0.0095). Amplificationof 1 I q 13 with distal 1 lq loss was found to occur more frequentlyin tumorsof the tongue, retromolartrigone, and buccal mucosa. In the 1 1 oralSCC cell lines examinedby cCGH,the most significantfindingwas the correlationof 1 I q I 3 amplificatioddistalI I q loss (1 I q22-qter)with decreasedpatient survival@ = 0.015). All patientswhose tumorslacked 11q13 amplificatioddistal1 lq loss (6/11) survived,comparedto only one of five patientswhose tumorshad I 1 q13 amplification and distal 1 Iq loss. This observationfurthervalidatesthe use of I lq13 amplification/ distal I Iq loss as a biomarkerfor patientprognosis,as has previously been reportedby severalgroups(reviewedin Gollin,2001), butdoes notruleout the possibilitythatdistal 1 1 q

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loss alonemay be associatedwith a poorprognosis,as thesetwo chromosomalregionscould not be analyzedseparatelyin this set of tumorcell lines. Distal I Iq loss is discussedlaterin this chapter.

209 Gain Amplificationof 20q 13 has been reportedinfrequentlyin SCCHN,although 20q gain is fairlycommon. We observed20q gain in more than half of our oral SCC cell lines examined by cCGH (Martin et al., 2008). Amplification is associated with high histological grade, aneuploidy, and high S-phase fraction in breast cancer (Tanner et al., 1995) and decreased disease-free survival of patients with node-negative breast cancer(Tanneretal., 1995;Rennstamet al., 2003). Key genes thataregainedoramplifiedon 20q 12-1 3 in breast and/or pancreaticcancer include ZNF2I 7, NCOA3, AIBI, MYBL2, CTSZ, and AURKA (Collins et al., 1998; Mahlamakiet al., 2002; Nessling et al., 2005). AURKA, the aurora-Akinase gene that maps to 20q13.2-13.3, has been found overexpressed in laryngealSCC leading to centrosomeamplification,aberrantspindleformation, and chromosomal instability (Guan et al., 2007). Their data also suggested that overexpressionof AURKA contributedto radioresistancethatwas reversibleby VX-680, a selective inhibitor.Pan et al. (2008) showed that treatmentof oral SCC cells with VX-680 led to apoptoticcell death. Furtherstudies are warrantedto understandthe upregulated genes on 20q, their prognosticsignificance,and therapeuticpotential.

3p LOSS Loss of the shortarmof chromosome3 is one of the earliestchangesin SCCHN, occurringalreadyin dysplasticoral lesions (Roz et al., 1996). 3p loss is mediatedby either isochromosomeformationor chromosomebreakage,most frequentlyat 3p14, the site of the FHIT gene and the most common chromosomalfragile site FRA3B (Durkin and Glover, 2007; lshii et al., 2007). Possibly as a result of this fragile site and otherregions proneto rearrangement, threediscreteregionsof loss have been reportedon the shortarmof chromosome3 in SCCHN(Maestroet al., 1993; Wu et al., 1994; Ishwadet al., 1996). We examined the FHIT gene in 26 SCCHN cell lines for deletions by Southernanalysis, for allelic losses of specific exons by FISH, and for integrityof FHIT transcriptsand found homozygousdeletionswithinFHITin threecell lines (Virgilioet al., 1996). In total,22 of 26 cell lines showed alterationsof at least one allele of FHIT, suggesting that loss of FHIT functionmay be importantin the developmentand/orprogressionof SCCHN.Alterationsin the FHIT gene and/orits proteinexpressionhave been observedin primarySCCHN and precursorlesions by severalotherresearchgroups.Recently,FHIT was linked,tothe DNA damageresponse pathway.This is pertinentto SCCHN, since we know that FHIT spans FRA3B. the most commonfragile site in the genome thatjust so happensto be susceptible to breakage by cigarette smoke (Stein et al., 2002) and is one of the most common chromosomalintegratjonsites of the HPV genome(Raginet al., 2004). As Ishii et al. (2007) point out, the DNA damage-susceptibleFRA3WFHIT chromosomefragile region, paradoxically,encodesa protein,FHIT,thatis necessaryfor protectingcells fromaccumulation of DNA damage,throughmodulationof checkpointproteinsHUS1 and phosphoCHEK1. TheFanconianemia(FA)gene, FANCD2, whichmapsto 3~26.3,may be anotherhot spotof geneticalterationsin SCCHN(Weberetal., 2007). FA patientshavea 50-fold higherriskfor all solid tumorscomparedto the generalpopulation,but a 700-fold higherincidenceof head and neck cancers(Rosenberget al., 2003). Often,patientswith FA are firstdiagnosedafter developing SCCHN before the age of 30. FANCD2 is importantbecause it is monoubiquitylatedin a FA core complex- and UBE2T-dependentmanner,targetingthe proteininto nuclear foci where it colocalizes with BRCAI, BRCA2FANCD1, and other proteins,

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continuingthe FA gene pathwaysignalingandenablingthe cellularresponseto DNA crosslinking agents (Jacquemontand Taniguchi,2007). Another potentially importantDNA damageresponsegene on 3p is topoisomeraseIIb (TOP2B, 3p24) (Hermsenet al., 2005). ThetopoisomeraseI1 (topo11) proteincatalyzesstrandpassageof double-strandDNA andis essentialfor chromosomalcondensationandsisterchromatidexchange.Duringmetaphase, it associates with the centromereand its inhibition,for example, by means of etoposide, resultsin cleavage within the centromere.One might speculatethat loss of this isoformof top0 I1 in the contextof 3p loss may resultin breakageandrearrangement atcentromeresand the many isochromosomesand centromericrearrangementsthat are seen in SCCHN. Numerousothertumorsuppressorgenes, includingRASSFI, mapto 3p and it is likely that also these and additionalgenes will be found to play a role in SCCHN.

8p Loss The shortarmof chromosome8 is lost in a largevariety of tumors,including SCCHN.Some of the losses are the resultof submicroscopicdeletions not detectableby chromosomebandinganalysis.Nearlyhalf of all SCCHNshowallelic loss in 81323 andeven homozygous deletions, suggesting the presence of TSG here (Ishwad et al., 1999; Sun et al., 1999; Scholnickand Richter,2003). The CSMDl gene is located within FRA8B at 81323.2 and its expressionis aberrantin most SCCHN as a resultof deletion, epigenetic silencing, andor aberrantsplicing (Richteret al., 2005). Loss of 8p23 in SCCHN is a statistically significant,independentpredictorof poor prognosis (shorteneddisease-free intervaland reduceddisease-specificsurvival)(Bockmuhlet al.. 2001). 9p LOSS Alterationsin band 9p21 are the most frequentgenetic changes in SCCHN (Gollin,200 1 ); van derRiet et al. ( I 994) firstreporteda high level of loss (72%)of 9p21-22 specificallyat an earlystagein SCCHN.The mechanismsof 9p loss includeisochromosome formationfor 9q as well as deletionsof variablesize. Noutomiet al. (2006) reportedthat9p loss is involved in the transitionfrom moderateto severe dysplasia, confirmingthis as anearlychangein thedevelopmentof SCCHN.Band9p21 is knownto containseveralTSG, p 14ARF/CDKN2A,plS/CDKN2B/MTS2, pl6/CDKN2A/MTSsI, pl8/CDKN2C, and p l 9 / CDKN2D, which encode cyclin-dependentkinase inhibitors(Jeannonand Wilson, 1998) and whose promotersareoften inactivatedby hypermetbylation.Alterationsin anyorall of thesegenes may leadto uncontrolledcell proliferationthroughloss of cell cycle checkpoint control,resultingin tumorigenesis.Martinetal. (2008) foundthatwhile 95%(19/20) of oral SCC patientswhose tumorscontainedan intact9p21-9pter region did not develop a new primarytumor(p = 0.0038),fourof eight patientswith 9p loss in the tumorcells developed new primarytumors.This is consistentwiththe findingsof Rosin et al. (2002) that3p and9p loss in premalignantoral lesions near the site of a first carcinomaconferreda 26-fold increasedrisk of developinga secondoral malignancycomparedwith lesions thatretained these two chromosomalregions.

7 7 q Loss The observationthat loss of chromosome I 1 distal to the 1 lq13 amplicon occursin SCCHNwas firstmadeby Jinet al. ( I 998b). Thisdeletionhasbeen shownto be the firststep in the 1 lq13 amplificationprocessin many SCCHN(Reshmiet al., 2007b). CGH analysisof ouroralSCCcells has revealedbothloss of chromosomalmaterialfrom 1lq22 and I lq13 amplificationin -50% of the cases examined(Martinet al., 2008). Distal 1Iq loss has been suggestedto occur at an intermediatestage in tumorprogression,following dysplasiabut precedingcarcinomain situ (Califanoet al., 1996). Loss of distal 1lq was reportedin two-thirdsof a varietyof SCCHNby Bockmuhlet al. (1998), laryngealSCCby

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Jarvinenet a]. (2006), andoralSCCby Freieret al. (2007). Haploinsufficiencyas a resultof loss of copies of genes involved in the cellular response to DNA double-strandbreaks, includingATM, MREII, CHEKI, and H2AFX, has been shown to promotechromosomal instabilitythroughgene mutation,amplification,and structuralchromosomeaberrations (Lobachevet al., 2002; Bassing el al., 2003; Celeste et al., 2003; Collin, 2005). OralSCC cell lines with distal 1 Iq loss havea deficientDNA damageresponseandreducedsensitivity to ionizing radiation(Parikhel al., 2007). The usefulnessof distal I Iq loss as a prognostic and therapyselection markerin SCCHNis being studied.

78s LOSS Loss of 18q occurs frequentlyin SCCHN and is associatedwith advanced tumor stage and a poor prognosis (Pearlsteinet al., 1998; Takebayashiet al., 2004). Five “minimally lost regions” have been identified on 18q, namely, 18q12, 18q21.1, 18q21.1-21.3, 18q22.2, and 18q23 (Papadimitrakopoulouet al., 1998; Takebayashi et al., 2000). Several TSG are mapped to the regions of loss, including DCC, DPC4, and MADR2, and the serpinpeptidaseinhibitorsSERPlNB3, SERPINB4, SERPlNB5, and SERPINBIS; they areexpressedin normaloral mucosa,skin,andculturedkeratinocytesbut areunderexpressedin oral SCC(Springet al., 1999;Nakashimaet al., 2000; Shellenberger et al., 2005). SERPINB 13 servesdual functions;intracellularly,it regulatesthe expression and secretionof angiogenicfactorsandas a secretedprotein,it inhibitsinvasion,migration, and tube formationin endothelialcells (Shellenbergeret al., 2005). Thus, loss of SERPINB13 expression in SCCHN appears to lead to a cellular imbalance resulting in angiogenesisand tumorgrowth. Kanazawaet al. (2007) showed that the galaninreceptor 1 gene (GALRI),which also maps to 18q23 and is often lost in SCCHN, inhibitscolony formationandtumorgrowthin vivo. TheirresultssuggestthatGALRl is a TSGthatinhibits cell proliferation. One goal of cancergenetic researchis that the newfound knowledgemay lead to new therapies.A majorproblemin thetreatmentof cancerpatientsis theemergenceof tumorcell resistanceto the drugsorradiationgiven. Severalreferenceshave been madethroughoutthe SCCHN section to biomarkersof therapeuticresistance. One of the most common in SCCHN is 1 lq13 amplification;the literatureclaims that SCCHN patientswhose tumors carrythis markerhave a poorprognosis.However,ourrecentfindingssuggest thatthe poor prognosisresultsfromresistanceto chemotherapyandradiotherapy, whichcanbe attributed to the firststep in the amplificationprocess,loss of distal 1 Iq (Parikhet al., 2007). Studies are currentlybeing conducted to reverse this resistancewith siRNA and targetedsmall molecule inhibitors.Anothermajoradvance in the handlingof patientswith SCCHN is based on the observationthat absence of activationof the PUMA proteincontributesto chemoresistanceandthatadenoviralPUMA gene therapyinducesapoptosisin cancercells independentof their TP53 status(Sun et al., 2007).

OTHER TUMORS OF THE NASAL CAVITY, SINUSES, ANDNASOPHARYNX Besides the dominatingSCCHN, many other benign,and malignanttumors arise in the head andneck area.Sinonasalcarcinomasincludenonkeratinizingsquamouscell carcinoma and sinonasalcarcinomas,uncommonmalignanttumorsarisingfrom the respiratory epitheliumof the nasalcavity andparanasalsinuses.Littleis knownabouttheircytogenetic characteristics.Gollin and Janecka( 1994) reporteda case of undifferentiatedcarcinoma

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with partial tnsomy 17 as the only change. In short-termcultures derived from three sinonasalSCC (Jinet al., 1995a),one tumordisplayedfive unrelatedpseudodiploidclones, the second had a highly complexkaryotypeincludingrearrangement of band 1 lql3, andthe third showed simple karyotypicchanges with loss of 6q materialand gain of 3q. These findingsaresimilarto those describedin SCCHNat othersites. Gil et al. (2006) analyzed14 sinonasalcarcinomasusing G-bandingafter short-termculture.Of nine SCC, three had abnormal karyotypes with numerical and structuralchromosomal anomalies. Of five undifferentiatedcarcinomas,two had abnormalkaryotypes:one had a near-diploidkaryotype with complexabnormalities,whereastheotherhada near-triploidcompositekaryotype with rearrangementsinvolving Ip, 6p, 7p, and 12q. The tumorsfrom all three patients who died of their cancer had abnormalkaryotypes,whereas only 2 of the 11 patients who survived had abnormaltumor karyotypes. Limited data are available regarding sinonasaladenocarcinomas.Complex karyotypicchanges were found in two such tumors (Jin et al., 1995a), both of which had rearrangements of bands91322 and 14qll. Invertedpapilloma (IP) is a proliferativelesion of the epitheliumlining the sinonasal tract.It often recursafter surgicalexcision and is sometimes associatedwith SCC of the sinonasalcavity.However,its presumedneoplasticnatureandputativerole as a precursor to SCC have not been confirmedat the molecularand genetic level. Three invertednasal papillomas were karyotypedafter a short-termculture by Jin et al. (1997). Two were characterizedby a single abnormalclone with t( 1 ;8)(p36;q1 1 ) andtrisomy7. respectively. The thirdpapilloma showed extremecytogenetic heterogeneity.Califano et al. (2000a) examinedthe patternof X-chromosomeinactivationin IP fromnine female patients.The X-inactivationwas informativein fourof nine tumors,and in each of these cases indicated a monoclonal inactivationpattern.IP and concurrentsinonasalSCC were also analyzed for LOH on 3p, 9p2 I , 11q 13, 13q1 1, and 1 7 ~ 1 3Losses . at loci in these regions occur frequentlyduring neoplastic transformationof the upper respiratorytract and can be detectedin SCCandthe progenitorlesions fromwhich they arise.LOHwas not detectedin any non-dysplasticareas from the TP, but LOH at one or more chromosomalloci was present in some of the concurrent SCC. Therefore, IP are most likely monoclonal proliferations,yet they do not fit the profile of a prototypic precursorlesion. Unlike squamousepithelialdysplasia, they do not appearto routinelyharborseveral of the key genetic alterationsthat are generally associated with malignant transformationof the upper aerodigestivetract. Intestinal-type adenocarcinoma (ITAC)of the nasal cavity and paranasalsinuses is an uncommontumorassociatedwith exposureto dusts of differentorigin. Few studieshave addressedthe molecularandgenetic alterationsin ITACand they have thenmainlyfocused on TP53, KRAS,and HRAS gene mutations(Perroneet al., 2003). In a studyof 28 sinonasal adenocarcinomas(Wu et al., 1996; Saber et al., 1998), intestinal-typeand papillary adenocarcinomaswere more common in patientsexposed to leatherdust. The mutation patternssuggestedpossibleexposureto a genotoxicagent(s) in thedust.A recentCGHstudy of 39 cases of papillary-tubular cylindercell adenocarcinoma(PTCC)(Korinthet al., 2005) detectedgenomic imbalanceabnormalitiesin all but two tumors.Chromosomalgains were most frequentlyseen on chromosomes/chromosome arms 12p(83%),7q (74%),8q (71 %), 20q (71%),11q (61%), 22 (59%).and 1 q (52%).Pronouncedoverrepresentations suggestive of high-level amplificationswere detectedon 8q (15 cases, 36%),7q (six cases, 14%),20q (five cases, 12%),13q14(threecases, 7%), lq22,5p, 12p,and20 (two cases, 5% each),and 2q24,3q13,3q22,7p, 1% 12, and 16q13(one case, each 2%).Frequentchromosomallosses occurredon 5q (81%), 18q(76%),4 (74%),8p (61%), 9p (60%),6q and 17p(52%each),and

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3p, 13q,and2 1 (50%each).Alterationswerequantitativelyandqualitativelyincreasedwith histopathologicalgrade. Esthesioneuroblastoma (EN) or olfactory neuroblastoma is believed to arise from the olfactoryepitheliumof the nasalvaultand is morphologicallyrelatedto Ewing sarcomaand otherperipheralprimitiveneuroectodermaltumors(pPNET).One such tumorwas reported to have a near-tetraploidchromosomeconstitution,with all chromosomesrepresentedat least three times and chromosome5 presentin multiplesof eight (Castanedaet al., 1991). A complex hyperdiploidkaryotypewas describedby Jin et al. (1995a) in anotherEN. Early cytogeneticstudiesof a tissueculturelineestablishedfroma metastaticlesiondemonstrated a reciprocaltranslocation,t( 1 1 ;22)(q24;q12), indistinguishablefromthe one thatcharacterizes Ewingsarcoma(Whang-Penget al., 1987). The karyotypesof metastaticor primaryEN cell lines were foundto containthreecopies of chromosome8, in additionto otherchromosomal aberrations,including the reciprocalt( 1 1;22)(q24;q12) (VanDevanteret al., I991). CGH analysisshowedmultiplechangesin one EN, includingoverrepresentation of chromosomes4, 8,11, and 14, partialgains of 1q and 17q,losses of the entirechromosomes16,18,19, andX, andpartiallosses of 5q and I7p(Szymaset al., 1997).CGHanalysisof EN by Riazimandet al. (2002)revealedrecurrentaberrationsincludingoverrepresentations of theentirechromosome 19, partialgains of 8q, 15q, and 2244, and deletions of the entire4q. In additionto these common aberrations,several single gains and losses also occurred.Based on the CGH findings,the authorssuggestedthatEN is not a partof the pPNETfamily.Thecombinedgain of geneticmaterialon 15q,22q, andchromosome8 mightbe characteristicforEN. In themost extensivestudyto date,Bockmuhlet al. (2004) usedCGHto examine22 EN from 12patients, including12 primarytumorsand 10 metastasesor recurrentlesions,andshoweda characteristic patternof 3p deletions and 17q overrepresentationsin all cases. Other important alterationsdetected in more than 80%of cases were deletions of lp, 3p/q, 9p, and lOp/q as well as overrepresentations of I7p13,20p, and 2%. Interestingly,the patternfor chromosomes andchromosomearms3,10,17q, and 20 was affectedalmostexclusively by deletions or overrepresentations,respectively.Markedoverrepresentationssuggestive of high-level amplificationswere seen on 1p34, 1q23-3 I , 7p21,7q3lt9p23-24,17ql 1-22, I 7q24-25,19, 20p, 2Oq13, and 22q13. Comparisonof tumorpairs from the same patientsdemonstrateda highconcordance,indicatingclonalityandgenetichomogeneityin thismalignancy.Analysis of metastaticor recurrentlesions indicateda higherpercentageof pronouncedalterations, such as high copy level DNA gains at I q34-qter,7q 1 1, 9p23-24,9q34, I3q33-34, 16~13.3, 16p11, 16q23-24, and 17p13. Specificalterations,for example,deletionsof chromosome1 1 andgainsof lp, appearto be associatedwith metastasisandworseprognosis.Takentogether, these resultsindicatethatEN is a distinctentity thatcan be distinguishedfromothersmall roundcell tumorson the basisof its geneticprofile.A recentstudyemployingGTG-banding, M-FISH,and locus-specificFISH complementedby molecular“karyotyping”using highdensity single nucleotidepolymorphism(SNP)arraysrevealedmany structuralaberrations, predominantlylocated on 2q, 6q, 21q, and 22q (Hollandet al., 2007). Nasopharyngeal carcinoma (NPC),a commonmalignancyin AfricaandSoutheastAsia, is stronglyassociatedwith EBV infection.Complex karyotypeshave been reportedin this tumor,with rearrangementand/or deletion of chromosome3 consistentlynoted (Huang et al., 1989;Waghrayet al., 1992;Wonget al., 2003). Thecummonchromosomalalterations identifiedby Hui et al. (1999) includedgains of Iq, 8, 12,19, and20 as well as losses of lp, 3p, 9p, 9q, I lq, 13q, 14q, and 16q. Using CGH, Chen et al. (1999) found that the most commoncopy numberincreasesoccurredon 12~12-13(59%), 1q21-22 (47%), 17q21 and 17q25(47%),1 lq13 (41%),and12ql3(35%).Themostfrequentlosseswerefrom3p12-14

OTHER TUMORS OF THE NASAL CAVITY, SINUSES, AND NASOPHARYNX

389

and 3~25-26(53%), 9p21-23 (41%), 33q21-32 (41%), 14q12-21 (35%), and 1 lq14-23 (29%).Comparedwith the primarycancers,no additionalchromosomalchangewas found in the recurrenttumors.However,the most frequentgain in recurrentNPC was at 1lq I3 (53%),comparedto 12p in the primarytumors.An increasein gene alterationscorrelated with clinical stage. Wong et al. (2003) carriedout CGH studies on six commonly used human NPC cell lines, finding consistent gains of 8q with a small overlappingregion identifiedat 8q21.1-22. Othercommongains were of 7p14-15,7qll.2-2 1,12q22-24, and 20q. Commonlosses of 3~12-21and 1 l q 14-qterwere detected.AlthoughSKYanalysisof cell lines revealed predominantlyunbalancedrearrangements,reciprocaltranslocations involvingchromosome2 wereseen, thatis, t( I ;2), t(2;3), andt(2;4).Additionalbreakpoints included3p21,3q26,5q31,6p21.1-25,7p 14-22, and8q22.Tanet al. (2006) found8 1.6%of NPC to harborgenomic alterations.They found significantlymore genomic alterationsin the tumors of patients who did not survive 5 years comparedto those who survived, suggesting that more genomic alterationspredict a worse prognosis. Neck lymphatic metastasisis consideredthe most importantclinical prognosticfactorin NPC. A similar patternof chromosomalabnormalitieswas seen in primarytumorsand metastaticregional lymphnodes (Yan et a]., 2005). The most commonaberrationswere gains of 5p, 12p, 12q, and 18p and losses of lp, 3p, 9q, 14q, 17p, and 16q. The metastases,but not the primary tumors,also exhibitedfrequentlosses involving 9p, 16p, 17q, 20q, 21p, 21q, and 22q and gainsof 8q and 8p. The most frequentuniqueaberrationin necklymphnodemetastaseswas loss of I 6p. observedin 100%of the lesionstested,andloss of 2Oq, observedin 77.8%of the lesions, and also gains of 8p and losses of 20q were common. Thepresenceof specific alterationsassociatedwith the regionallymph node metastasesof NPC suggests thatthese changes are involved in the spreadingprocess. More recent studies using aCGH have confirmedsomeof thepreviousfindingsin NPC,withchromosomalgainsoftenfoundon Iq, 3q, Sq, I lq, I2p, and 12q (Hui et al., 2005). Frequentnonrandomlosses were identifiedon chromosomearms3p, 9p, l l q , 14q, and 16q. In addition,novel minimal regions of gain were found,including3q27.3-28, 8q21-24, Ilq13.1-13.3, and 12q13, which may harbor NPC-associatedoncogenes. A gain of 1 lq13 was the most frequentlydetected chromosomal aberration,including a 5.3-Mb amplicon.Concordantamplificationof this region with overexpressionof CCNDl was found in NPC cell lines, xenografts,and primary tumors. Knockdown of cyclin DI by small interferingRNA in NPC cell lines led to a significantdecrease in cell proliferation.These findings suggest that CCNDl is a target oncogeneat 1 I q 13 in NPC.As in SCCHN(see above),a numberof othergenes may also be involved in NPC. An evolutionarydendrogramanalyzing CGH data from previously publishedNPC cases (n= 103) concludedthatconsistentloss of 3p is an importantearly event in NPC development(Shih-Hsin Wu, 2006). Chromosome12 gain appearsto be anotherimportantearly event thatmay representa subclassdifferentfrom 3p loss-related NPC. The tree models also suggested the existence of at least two subclassesof 3p lossderivedNPC, one markedby I q gain,9p loss, and 13qloss andtheothermarkedby 14qloss, 16q loss, 9q loss, and 1p loss. Like SCCHN,deletionsof 3p and9p appearto be earlyevents in NPC tumorigenesis(Chanet al., 2000,2002). High frequenciesof allelic imbalancewere observedon 3p (96.3%),9p (85.2%),9q (88.9%), I Iq (74.1%), 12q (70.4%), 13q(55.6%), 1% (85.2%), and 16q (55.6%).In addition,LOH on chromosomearms Ip (37.0%), 5q (44.4%), and 12p (44.4%) was also common in NPC. Multipleminimalcommon deleted regions, 7 4 0 c M in size, were identifiedat 3~14-24.2, 1 lq21-23, 13q12-14, 13q31-32, 14q24-32, and 16q22-23. Frequentdeletions of these regions imply the presencehere of TSGthatm a y be involvedin thedevelopmentof NPC. ConsistentLOHon 3p, 9p, and 14qin

390

TUMORS OF THE UPPER AEROOIGESTIVETRACT

almost all tumorssuggests thatsuch changes are criticalevents in NPC tumorigenesis(Lo et al., 2000). The most common molecularalterationwas reportedto be inactivationof the p l 6 K D K N 2 A gene by homozygous deletion (Lo et al., 1995). Othergenes present in minimal common deleted regions are H2AFX at I lq23, EDNRB at 13q22, E-cadherin (CDHI) at 16q22, and RBL2 at 16q12.2 (Claudioet al., 2000; Lo and Huang, 2002; Lo et al., 2002; Tsaoet al., 2003). Deletiono l the shortarm of chromosome3 emergesas one of the most importantgenetic abnormalitiesin the tumorigenesisof NPC. Mapping and functional studies have targetedNPC-relatedTSG to 3p21.3, such as RASSFIA (Chow et al., 2004; Panet al., 2005). AnotherpromisingcandidateTSG in NPC is ZMYNDlO (Yau et al., 2006). Overexpressionof PIK3CA, a candidateoncogene located at 3q26.32, was foundin NPCcell lines andxenogmfts(Oretal., 2005), suggestingthatit may be involvedin the tumorigenesisof NPC. DLECl, locatedat 3~22.2,was recentlyidentifiedas a candidate TSG in lung, esophageal,and renal cancers. Limitedcytogeneticdataareavailableonjuvenile nasopharyngealangiofibroma (JNA), arare,oftenrecurringbenigntumorthatis mostlyseen in adolescentmales.OneCGHstudy analyzed22 JNA, includingsix recurrences(Heinrichet al., 2007). Of the 13 primaryJNA without laterrecurrence,DNA gains were identified on autosomesin only two samples. Acrossall 22 samples,gains occurredin more thanone sampleon chromosomesarms 1p, 9q, 109, 12q, 16p, 16q, 17q, 19p, 19q, 2Oq, and 22q. Losses were found in a single case, exclusively on chromosome4. Sex chromosomes were frequently affected in primary tumorsand recurrences.Therewas no correlationamongtumorstaging,age, and chromosomal alterations.These resultssuggest that in JNA, the activationof oncogenes is more importantthanthe inactivationof TSG. Autosomalgains in the primarytumorarepotential markersfor increasedrisk of recurrenceafter surgicalremoval.

SALIVARY GLANDS The genomic changes underlyingbenign and malignanttumorsof the salivaryglandsare poorly understood.This is due in partto the low incidenceof these tumorsand theirwide histologicalvariation.Generally,the occurrenceof polysomy is thoughtto representa step towardmalignancyin varioustumorsof the salivaryglands(Gotteet al., 2005). In addition, recentstudiesrevealedLOH in at least one informativelocus in 90%of benigntumorsand in all malignanttumorsanalyzed(Honjoet al., 2007). The most frequentfindingsarelisted in Table 1I .2. Acinic cell carcinoma is a malignantepithelialneoplasmof the salivaryglandsfor which no consistentcytogeneticalterationshave been reported.A study by Sandroset al. (1 988) showed clonal rearrangementsinvolving the long armof chromosome6, mainly terminal deletionswith breakpointsin 6q22-25. Otherabnormalitieswereloss of the Y chromosome, trisomy 8, and deletions of I Iq. The polyclonalityof this entity was underscoredby the finding of multipleabnormalitiesin cell cultures(Jin et al., 1998a). A subsequentstudy revealedchromosomalalterationsin 84%of the tumorsanalyzed,with LOH of 4~15-16, 6p25-qter, and 17pl1 most frequently observed (El-Naggar et al., 1998). LOH was significantly associated only with tumor grade; no correlationbetween LOH and other clinico-pathologiccharacteristicsor DNA content was apparent. Mucoepidermoid carcinoma (MEC) is characterizedby the translocationt(l I ;19)(q2I ; p 13)(Fig. 11.2;Nordkvistet al., 1994a;Horsmanet al., 1995;El-Naggaret al., 1996),which probablyrepresentsa primaryevent in the developmentof this malignancy.Nordkvist

SALIVARY GLANDS

391

TABLE 11.2 Cytogenetic Alterations in Salivary Gland Tumors Chromosomal Gains (Frequency)a

Chromosomal Losses (Frequency)a

Acinic cell carcinoma

8, Ilq

Y

Mucoepidermoid carcinoma

16, 20

TumorType

4p (52%), 17p (50%), 5q (41%), 6q (41%), 4q (32%),Ip (28%). Iq (27%), 5p (16%),6p (9%) t( 1 1 ;19)(q21 ;p13) (50%)

(20% each) Adenoid cystic carcinoma

ChromosomalRearrangements or Breakpoints(Frequency)a

3, 9, 1 1

17

inv(I )(p32-33q42) (20%) t(6;15)(p12;q25) (20%) 9p13-23 (translocations)(46%)

16p (25%) 17q (15%)

12q (33%)

12q12-13 (30%)

@, 13q, 19 (25% t(6;9)(q21-24;~13-23) (32%)

each) 20 22q (30%) Polymorphous low-grade adenocarcinoma

22‘

6q (30%) 1 Iq’

Basal cell adenocarcinoma Carcinomaexpleomorphic adenoma

9p21.l-pter, 18q21.l-22.3, 22q11.23-13.31’ 7, 8, and 22a

t(6;12)(p21;q13)(30%) 17p12-1 3 (translocations)(20%) 8q12 (60%)

(50%), 12q12-13 (33%), 12q22 12~12.3 (33%) 3p21 (30%) t(6;12)(p21;q13)(25%)

2q24.2, 4q25-27‘

Y, 1,6,9, 11, 14, t(10;12)(p15;q14-15)b 15, 17, 19-21’ 5q‘

8q12 rearrangements and alterationsof 12ql3-I 5’ der(1 ;I 4)(qIO;ql0)’. del(6)(ql5q34), de1(6)(q15q34), der(8)’, t( 1;8)(q12;q12.2),der(9;19)(qlO;q10), add(14)(pI1.2), i(2O)(qlO),der(2l)t (8;21)(qI1.2;q22.3),+ der(2l)t(8;2 I)’ 8q 12, most frequentlyt(3;8)(p21;q12) (30%) t(5;8)(pl3;q12) (40%) 12, especially bands 12q13-35 (15%) t( I ;4;8)(p32;q35;q12)’ del(12)(pl I .2p12.I )’ ins(9;8)(p22;ql2q21.lb t(1;12)(q25;q12)’

+

Pleomorphic adenoma

Myoepithelioma

8 (10%) Iq, 8q (lo%), 5 (2%). Basalcell adenoma 8,4’

9%13q’

+

t(7;13) and inv(l3)’ (continued)

392

TUMORS OF THE UPPER AERODIGESTIVE TRACT

TABLE 11.2 (Continued)

Tumor Type

Chromosomal Gains (Frequency)''

Chromosomal Losses (Frequency)"

Warthin's tumor

5h

X (89), Y (l5%), 5'

Chromosomal Rearrangements or Breakpoints (Frequency)a t(l1;19)(q21;p13) (20%) t( I I; 19;16)(q21 ;p 12;p 13.3) (8%) t(6;8)(p23;q22) (8%) t(6; 15)( p21 ;ql5) (8%) Ip22,3p26, 1 1 ~ 1 3 ~

~

UFrequenciesare not included when few cabes are reported I except for I(H8,see footnote b) or data not available. blOO% in one to five reported cases.

et al. (1994a) showedthatat leasttwo different,partiallyoverlappingcytogeneticsubgroups exist: ( I ) cases with structuralrearrangementsof 1 1q 14-22, including t(1 I ;IS), and (2) cases with single or multiple trisomies, either alone or in combinationwith structural rearrangements.Interestingly,the t( 1 1 ;19)(q21 ;p13) is a characteristicaberrationalso in adenolymphoma(Warthin's tumor; see below) as well as in hidradenomaof the skin (Chapter21). In all the threetumortypes, the translocationresultsin a fusion of the CTRCl and MAML2 genes (Tonon et al., 2003; Behboudi et al.. 2006). The biologic role of the translocationand fusion gene is discussed in more detail in Chapter2 1. Unlike many other carcinomas,adenoid cystic carcinoma (ACC) has relatively few changesin DNA copy numberoverall(El-Rifaiet al., 200 1). Monosomy 17 andpolysomyof chromosomes3,9, and 1 I have been the most frequentlyencountered(Gotteet al., 2005). The study by Nordkvist et al. (1994~)revealed recurrentrearrangementsof 6q23-24 (deletions or translocations),9pl3-23 (translocations),and 17~12-13 (translocations). t(6;9)(q21-24;p 1 3-23) seems to be a nonrandom,primaryaberration.Martinset al. (2001 ) reported an ACC with t(6;12)(p2l;q13) associated with de1(6)(q23) and addition of unknown chromosomal material to 9 ~ 2 2 .A frequent (33%) finding was loss of 12q12-I3 (El-Rifai et al., 2001). In addition,deletions of 6q23-qterand 13q21-22 and gainsof chromosome19 wereobservedin 25-38% of ACC.Thesefindingsindicatethatloss of 12q12-I 3 may be importantin the developmentof ACC and suggest the presenceof a new TSG here (El-Rifaiet al., 2001). Analysis of a series of 27 ACC (Freieret al., 2005) showed the most common aberrationsto be gains of 22ql3 (nine cases), 16p (seven cases), and 17q (four cases) as well as losses of 6q (six cases). The overall prevalenceof gains of 22q I3 was 30% by FISH analysis, irrespectiveof histologic differentiation

11

19

FIGURE 11.2 A t( 1 1 ; I 9)(q21 ;p13) resulting in a CRTCI/MAMLZ gene fusion characterizes mucoepidermoid carcinomas, adenolymphomas,and hidradenomasof the skin. Arrowheads indicate breakpoints (Courtesy of Dr.Goran Stenman).

SALIVARY GLANDS

393

(cribrifordtubular versus solid) or tumorevent (primaryversusrecurrent).Yu et al. (2007) analyzedgenomic DNA obtainedfrom22 primaryACC and two ACC-derivedcell lines by high-density oligonucleotide single nucleotide polymorphism genotyping arrays. The tumorsamples revealed a mean of three deletions per tumor,and no consensus areas of deletionwere observedacrossthe majorityof tumors.Similarly,copy numberanalysisof primaryhybridizationdatarevealedno consensusareasof gene amplification.These data indicatethat many, if not most, ACC have predominantlystable genomes and that gene mutationor epigeneticevents thatcannotbe detectedas gross alterationsof chromosomal structureare likely to underliethe malignanttransformation. Few studies have focused on polymorphouslow-gradeadenocarcinomacytogenetics. These low-grade tumors have a putativecommon histogenesis with ACC and can show chromosome 12 abnormalitiesinvolving 12q12-13, 12q22, and 12~12.3.Alterations in 8q12, t(6;12)(p21;q13), and monosomy 22 have also been reported(Martins et al., 2001). Limited data are available on epithelial-myoepithelial carcinoma. Karyotypes are normalor show no distinctalterations(Martinset al., 1996; Mitelmanet al., 2008). In basal cell adenocarcinoma(BCAC),Toida et al. (2001) identifiedgains of 9p2 1.1pter, 18q21.l-22.3, and 22q11.23-13.31 as well as losses of 2q24.2 and4q25-27. Gain of 22q 12.3-1 3.1 is common to both adenoidcystic carcinomasand BCAC. The cytogenetics of salivary duct carcinomahas received little attention.The most prominentfindingso faris LOHin chromosomeband9p21, whichcontainsthep/6/ZNK4a/ CDKN2NMTSI tumorsuppressorgene thathas been implicatedin a varietyof tumortypes, including melanomas and carcinomasof the head and neck, esophagus, and pancreas (Cerilli et al.. 1999). Data on myoepithelialcarcinomasare also limited, but point to a relative scarcityof detectablecytogeneticalterations(Hungermannet al.. 2002). In some cases, aberrationsof chromosome8 have been seen, consistentwith observationsin salivarygland carcinomas of otherdifferentiationtypes. In a carcinoma ex pleomorphicadenoma, a de1(5)(q22-23q32-33) together with a t( 10;12)(p15;q14-15) was found(Roijeret al., 2002), with the 12q breakpointat the 5’ end of the high-mobilitygroupproteingene HMGA2and translocationof the entiregene to the der(lo), followed by deletiodamplificationof a segment containing the HMGA2 and MDM2 genes from this chromosome.Frequent8q12 rearrangementsand alterationsof 12ql3-15, with HMGA2andMDM2 amplification,have been highlightedin otherstudies (Rao et al., 1998; Jin et al., 2001) and are also presentin PA. Otherrecurrentabnormalities with potential impact on malignant transformationof pleomorphicadenoma are copy numbergains of chromosome 7 (Roijer et al., 1999). Overall, the studies suggest that markedchromosomaland DNA contentabnormalitiesare presentin this malignancyand the series of genetic events underlyingtumorprogressionis about to be deciphered. Littleis known aboutcarcinosarcoma,a very rareandaggressivemalignancy.LOH was seen in bands 17~13.1,17q21.3, and 18q21.3 (Gotteet al., 2000). Only three salivarygland squamouscell carcinomashave been published;del(6q) was noted in all three tumors(Jin et al., 1995b). Extensivecytogeneticanalyseshave been carriedout on benign salivarygland tumors, includingpleomorphicadenoma(PA),the most commonparotidglandneoplasm(Bullerdiek et al., 1987, 1988a, 1993; Market al., 1988; Sandroset al., 1990). At least two-thirdsof salivary gland adenomas have nonrandom structuralchromosomal changes. Several tumor subgroupscan be delineated based on karyotypes.The most prevalentsubtype is

394

TUMORS OF THE UPPER AERODIGESTIVE TRACT

3

8

FIGURE11.3 The reciprocaltranslocationt(3;8)(p2I ;q 12) is a characteristiccytogenetic rearrangement in pleomorphic adenoma of the salivary glands. Arrowheadsindicate breakpoints (Courtesyof Dr. GoranStenman).

characterizedby rearrangementsinvolving 8q 12, often as t(3;8)(p2I ;q 12) (Fig. 1 1.3). In what appearsto representvarianttranslocations,8q I2 is found to be recombinedwith a Less frequentwide rangeof otherchromosomes,sometimesin complex rearrangements. ly, changesof 3p are seen withoutconcomitant8q alteration.The second subgroup,which comprises one-fourth of all karyotypically abnormalcases, consists of tumors with aberrationsof chromosome 12, especially bands 12ql3-15. These rearrangementsare not seen in tumors with 8q12 involvement. The rearrangementsof 32q13-I5 may be translocationswith various partners, the preferred partner being the short arm of chromosome9, with breakpointsin 9p12-24 (Stenmanet al., 1993), or inversions.The third and last subset encompassesa cytogeneticallyheterogeneousgroupof tumorsthat have neither8q nor 12q changes. Attemptshave been made to correlatethe cytogenetic subgroups with clinico-pathologic features. Bullerdiek et al. ( 1993) found marked differences among them with regard to patient age, histologic subtype, and in vitro cellular morphology. Patients with tumors expressing 8q12 rearrangementswere in general youngerthan those having karyotypicallynormaltumors.Whereasin all cultures from tumors carrying 8q12 changes, the predominantgrowth patternwas epithelial, culturesfrom tumors with 12q13- 15 rearrangementsgrew in monolayersand the cells were fibroblast-like.Most, but not all, culturesfrom karyotypicallynormal tumorshad “mesenchymal”morphology.The histologicalcomparisonsrevealedthatthe lattertumors also typically had a higher contentof stromalcells in vivo than did .tumorscharacterized cytogeneticallyby rearrangement of 8q12. The targetgene affected by the chromosome8 aberrationswas shown to be the P U G 1 gene at 8q12, which encodes a zinc finger transcriptionfactor (Kas et al., 1997a, 1997b; Debiec-Rychteret al., 2001). The most common abnormality,the reciprocaltranslocationt(3;8)(p21;q12), often results in promoter swappingbetween P U G 1 and the constitutivelyexpressed gene for beta-catenin (CTNNBI),a proteininterfacefunctioningin the WGWNT-signalingpathwayinvolvedin specification of cell fate during embryogenesis.Due to the t(3;8)(p21;q12),P U G 1 is activatedand expressionlevels of CTNNBI are reduced.Activationof P U G 1 was also observedin an adenomawith a varianttranslocationt(8;15)(q12;q14).This would indicate that P U G 1 activationdue to promoterswappingis an importantevent in salivarygland tumorigenesis(Kas et al., 1997b). Whereast(3;8)(p21;q12) is the most frequenttranslocation, also many other chromosomesegmentscan functionas translocationpartnersfor 8q12 and 12q13-15 (Sandroset al., 1990; Bullerdieket al., 1993). A t(5;8)(p13;q12)has .alsobeen described,leadingto a LIFR-PUG1 fusion (Voz et al., 1998). The HMGAZ was

ESOPHAGEALCANCER

395

identifiedas the targetgene affectedby the 12q13-15 breakpointin PA as in several benign mesenchymaltumors(Asharet al., 1995; Schoenmakerset al., 1995). Additionalcomplex abnormalitieswere describedrecentlyby Kandasamyet al. (2007), includingt( 1;4;8)(p32; q35;q12), t(5;8)(pl3;q12),and ins(9;8)(p22;q12q21.1),all of which disruptPLACI. Myoepithelioma is a rare benign tumor with relatively few identified cytogenetic abnormalities.The observedalterationshave affectedchromosomes1,9, I2 and 13, mainly with t( 1 ;12)(q25;q12),de1(9)(q22.lq22.3),and del(l3)(q12q22) (El-Naggaret al., 1999). Chromosome8 can also be involved,consistentwith findingsin salivaryglandcarcinomas (Hungermannet al., 2002). Chromosomeaberrationshave been reportedin about20 adenolymphomas (Warthin’s tumor) (Bullerdieket al., 1988b;Market al., 1989, 1990;Nordkvistet al., 1994b).The most characteristiccytogenetic feature,in addition to numericalchanges (loss of the X or Y chromosome, trisomy/monosomy 5), is a nonrandom t( 1 I ;19)(q21 ;p13), that is, the same translocation (Fig. I 1.2) leading to the same CTRCI-MAML2 fusion (Enlund et al., 2004) seen in 50%of mucoepidermoidcarcinomas.This points to an intriguing biological similarity between adenolymphomasand mucoepidermoidcarcinomas. As mentioned earlier,the same fusion gene has also been detected in skin hidradenomas (Chapter 2 1). Several additional translocationshave also been reported, including the complex t(11;19;16)(q21 ;PI 2;p13.3), the balanced two-way translocationst(6;8) (Martins (p23;q22)and t(6;15)(p21;q15),as well as lp22,3p26, and I lp13 rearrangements et al., 1997).

ESOPHAGEAL CANCER Most esophageal tumors are squamous cell carcinomas (ESCC) or adenocarcinomas (EAC). Consistentcytogenetic alterationsin these tumorsare listed in Table 1 1.3. Several cytogenetic abnormalitiesassociated with ESCC have been reported.Kwong et al. (2004) found chromosomalgains involving,in orderof decreasingfrequency,3q, 8q, 5p, 7q, 15q,20p, 20q, lq, 7p, 2p, and 12p.Most high-levelamplificationswere seen in 12p, with a minimumoverlappingregionat 12pI3. The most frequentlosses involved 3p, 4q, 4p, 3q, 9p, 19p, and the whole chromosome13. No significantcorrelationwas foundbetween recurrentchromosomalaberrationsandpathologicalstage.However,atadvancedstages(m and IV), gain of 12pandloss of 3p were associatedwith shortrelapse-freesurvival.Thegain of 12p was an independentprognosticatorfor relapse-freesurvival postesophagectomy. A study by Shiomi et al. (2003) reconstructedthe sequence of clonal divergence and evolutionfroma stemlineby comparingthe cytogeneticprofileamongdifferenttumorparts and classified the DNA copy number changes into those occurring before and after tetraploidization. The resultsindicatedthatgains of 3q, 8q, 1 Iq, and 14q were earlyevents, whereaslosses of 3p, 5q, 13q, and 21q, and gains of lp and Xq seemed to representlater events. Gain of 3q was identified in 75% of cases, with a smallest common region of overrepresentationat 3q26.2, and was considered to have occurred frequently in the diploid stemline. This 3q gain was detected by CGH in 40-75% of ESCC (Du Plessis et al., 1999;Packet al., 1999;Rumpelet al., 1999;Tadaet al., 2000; Kwonget al., 2004) and appearsto representa common step in tumorigenesisof SCC of the upperaerodigestive tract(Heselmeyeret al., 1997; Kirchhoffet al., 1999). It was hypothesizedthat one of the oncogenes responsiblefor this is TERC(Soder et al., 1997, 1998), which maps to 3q26. A commonsite of LOH in ESCC,SCCHN,andesophagealdysplasiais chromosomearm 3p

396

TUMORS OF THE UPPER AERODIGESTIVE TRACT

TABLE 11.3 Cytogenetic Alterations in Esophageal Tumors

TumorType Squamouscell carcinoma

Chromosomal Gains (Frequency)

Chromosomal Losses (Frequency)

ChromosomalRearrangements or Breakpoints(Frequency)

3q (7 I %)

3p (359)

t(3;7)(p21;qll)(5%)b

4q (27%) 4p (23%) 5q (20%) 13q (20%) 2 1q (20%) 3q (19%) % (17%) 19p ( 1 7 ~ ) 13 (15%)

der(1l)t(4;I l)(q727;q23)(5%)b der(1l)t(7;1l)(p?15;p?13)(5%)’

18, I7p (75% each)

A11 chromosomearmsexcept lop, 16q, 18q, 19p, 20q, X” Most frequent:Ip (65%), 3q (65%), 22p (40%), I 1p (33%) iso(3q) (25%), iso( 13q), iso(l4q) (15%)

I 1q (70%) 14q (69%) 8q (66%) 5p (52%) 7q (298) 15q (29%) 20q (29%) 1q (27%) 7p (27%) 1p (25%) Xq (25%) 2p (23%) 12p (23%) 20p (2 I %) 14q (69%) Adenocarcinoma 8q (80%) 22p (70%)

4 (66%)

12 (66%)

21 (65%)

17 (65%) I 1p (62%) 20q (60%) 6 (58%) 7 (58%) 1 1 (50%) 8 (50%) 2P, 7P, 1oq (47% each) 6p (37%) 14 (33%) 15q (33%) 17q (30%) 20 (25%)

18q (54%) Y (53%) 4q (50%) 5q, 9p (43% each) 7q (33%) 14q (30%) 4 (66%)

“Menke-Pluymers et al. ( I 996). hRosenblum-Vos et al. (1993).

(Aoki et al., 1994; Ogasawaraet al., 1995; Montesanoet al., 1996; Shimadaet a]., 1996;

Bederet al., 2003; Shiomi et al., 2003). Fromthe findingsof clonal divergence,this change was inferredto occur at random,not only in the stemlinebut also in sidelines (including those with aneuploidy).The 3p loss has been predictedto be a laterevent than the 3q gain, althoughthis remainscontroversial.LOHhasbeen foundat chromosomalloci on 3p, 5q, 9p, 9q, 13q, 17p, 17q,and 18q (Montesanoet al., 1996; Hu et al., 2000; Shiomiet al., 2003), as

ESOPHAGEAL CANCER

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were amplificationsof MYC (8q24), FGFR (17q21-22), and CCNDI (1 lq13) (Montesano et al., 1996). Peraltaet al. (1998) investigatedthe potentialexistence of TSG on chromosome 5 that may contributeto the development of esophageal carcinoma.LOH was observedin at least one of the loci analyzed in 67% of esophagealtumors(both ESCC andEAC). A novel locus, D5S667 at 5p15.2,exhibitedthe highestfrequencyof LOH(44%) in these tumorsalong with anotherpreviously reportedregion of frequentdeletion, IRFI (5q31.1). In an additionalseries of ESCC and EAC, a detailedLOH analysis of subband 5p 15.2 was conducted.Overall,LOHat the D5S667 locus was observedmorefrequentlyin ESCCthanin EAC. This significantrateof LOH of a distinctregionof 5p implicatesthe existence here of a TSG locus involved in esophagealcarcinoma. Chromosomebanding,FISH, and CGH studieshave identifieda complex arrayof abnormalitiesin EAC with or without associatedBarrett’smucosa. Early studies suggested that the patternsof cytogenetic changes did not differ between adenocarcinomasarising in Barrett’sesophagus (BE) and those in the distal esophagus withoutBarrett’smucosa (Menke-Pluymerset al., 1996). Losses of chromosomes4, 18, 21, and Y were the most frequentnumericalchanges. Loss of the Y chromosomewas observedin 3 1% of tumors frommales.Gainsof chromosomes14 and20 werealso frequent.Structuralrearrangements wereobservedin most abnormalkaryotypes(68%).The chromosomearmsmostfrequently rearrangedwere lp, 3q, 1Ip, and 22p. The chromosomearm most frequentlyexhibiting losses was 1 p. with a shortestregion of overlapat I p22-33. The chromosomearmsmost ofteninvolvedin gainswere I 1 p and22p, andi(3q) was the isochromosomemostfrequently identified.Gainsof chromosomes6,7, I I and 12 were also reported(Personset al., 1998). A more recent study of a series of 20 Barrett’s adenocarcinomas (BA) found numerical abnormalitiesof chromosomes7,8,11,17, and Y in an even higherpercentage(upto 60%) of the analyzed tumors(Beuzen et al., 2000). The aberrationsseemed to have occurred early in the transformationof Barrett’smucosa. Trisomiesfor chromosomes7,8, 1 I , or 17 appearedto be the most frequent.CGH analyses suggestedthat 14q31-32.3 is frequently deleted in adenocarcinomasof the gastroesophagealjunction (Dinjenset al., 2006). Barrett’sesophaguscarriesa 30-100-fold increasedrisk of adenocarcinoma,which is thoughtto develop via a metaplasia-dysplasia-carcinoma progression.Precursorlesions, such as high-gradedysplasia,are notoriouslydifficultto identifyand gradehistologically, thereforeadditionalprognosticmarkersareneeded,and cytogeneticchangesmightfit such a role. Several studies have addressedthe cytogenetic alterationsfound in premalignant stages of Barrett’sadenocarcinoma,in additionto the malignanttumoritself. According to Wu et al. (1998), there is an increasein the prevalence of chromosomallosses in the Barrettmucosa-columnardysplasiaadenocarcinomasequence:17ploss occurredin 14%of Barrett’smucosae,42% of low-gradedysplasias,79%of high-gradedysplasias,and75%of adenocarcinomas; likewise, loss of 18qoccurredin 32,42,73, and 69%,andloss of 5q in 10, 21,27, and46%.Clinicalstagewas a very strongprognosticfactorfor survival,and patients whose tumorsshowed allelic loss of both I7p and 18q had shortersurvivalthandid those whose cancercells showedonly one or no allelic loss. The dataindicatean accumulationof genetic alterationsthatparallelsthe dysplasia-adenocarcinomasequencein the esophagus, andthatthe 18q and 17plosses occurearlierthanthe 5q loss. Gleesonet al. (1998) detected allelic imbalancesin over45%of informativecases of EACon chromosomearms3q (65%), 4q (7 1 %), 5q (59%),6q (59%),9p (SO%),9q (47%),12p(47%), 12q (65%), 17p(76%),and 18q (75%).Allelic imbalancewas detectedat several loci in the premalignantepithelium from five of the sevencases studied.Theseloci includedseveralchromosomalarmsthathad demonstratedhigh levels of allelic imbalancein EAC, namely,4q (one case), 5q (two cases),

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9 (threecases), 12q (five cases), I7p (fourcases), and 18q (two cases). Novel microsatellite alleles were detected in both premalignantand malignant Barrett’sepithelium.In three cases, dysplasticBE andadjacentadenocarcinomademonstratedthe same patternof novel microsatellitealleles at a numberof loci. These datasupportthe existenceof chromosomal loci thatmay be specificallyinvolvedin the histologicalprogressionof BE. The detectionof shared novel microsatellitealleles in premalignantand malignant BE appearedto be consistent with a process of clonal expansion underlying this progression (Gleeson et al., 1998). Additional studies found the most frequentchromosomalalterationsin BA to be gainson 8q (80%),20q (60%),2p, 7p, and IOq (47%each),6p (37%), 15q (33%),and 17q (30%)(Walchet al., 2000a, 2000b). Losses were observedpredominantlyfrom the Y chromosome(76%),4q (50%), 5q and9p (43%each), l8q (40%),7q (33%),and 14q(30%). High-levelamplificationswere observedon 8q23-qter,8p I2-pter,7p 1 1- 14,7q21-3 I , and 17qll-23. Recurrentchromosomalchanges were also identifiedin metaplastic(gains on 8q, 6p, and 109, losses on 13q,Y, and 9p) anddysplasticepithelium(gains on 8q, 2Oq, 2p, 1 Oq, and 15q as well as losses of or from Y, 5q, 9p, I3q, and 18q). Amplifiedchromosomal regionson chromosomearms2p and 1Oq were detectedin both Barrett’sadenocarcinoma and premalignantlesions. Interestingly,there was an increase in the average numberof detectedchromosomalimbalancesfromintestinalmetaplasiato low-gradedysplasia,highgradedysplasia,Barrett’sadenocarcinoma,and lymph node metastases.The detectionof common chromosomalalterationsin premalignantlesions and adjacentcarcinomasprovides furthersupportfor the idea of clonal expansion.However,the Occurrenceof several chromosomalchangesin an apparentlyrandomorderrelativeto one anothersuggests that clonal progressionis complexratherthanlinear.Thisreflectsthe possiblepresenceof many divergentneoplasticsubpopulationsand underscoresthe importanceof samplingerroras a majordifficulty associatedwith the surveillanceof Barrett’spatients.Dolan et al. (1 999) conducteda studyaimedat identifyingat which histologicalstageof carcinogenesisLOH at various sites occurs. IdenticalLOH was detected in premalignantand malignanttissues from4of 17 patients,namely,at5q21-22, 17pl1.1-12, 17~13.1,18q21.1, and 18q23-qter. These results,in conjunctionwith those of otherstudies,suggest thatLOHat the sites of the DCC, APC, and TP53 tumorsuppressorgenes occursbefore the developmentof adenocarcinoma in BE, and thereforerepresentpotentialbiomarkersof neoplasticprogressionin patientswith BE under endoscopic and histological surveillance(Reid et al., 2001). A subsequentstudyemployedLOH analysisof endoscopicbiopsiesfrom48 patientsas partof a Barrett’ssurveillanceprogram,using 14 microsatellitemarkersshownpreviouslyto detect LOH in morethan30%of EAC (Dolan et al., 2003). Patientswere followed up endoscopically fora medianof 5 years. LOHwas detectedin nine patients.In threepatientswithLOH on 5q or 9p, the pathological changes did not progress beyond metaplasia. LOH at 17~11.1-13 was detected in six patients, all of whom demonstrateddysplasia and/or carcinomaduringfollow-up (fourlow-gradedysplasias,one high-gradedysplasia,and one adenocarcinoma).It was concluded,therefore,thatLOH at 17pl I , 1-1 3 identifiespatients with BE at risk of neoplasticprogressionand, togetherwith histologicalanalysis,can help determinethe frequencyof endoscopyduringpatientsurveillance.In anotherstudy(Petty et al., 1998), over 50%of the Barrett’sandcardiaadenocarcinomas demonstratedloss of an allele at one or more informativedistal 17q loci. One commonoverlappingregion of loss involved loci mapping to distal 17q24-proximal17q25, which was thought to define a potentialchromosomalregiondistalto BRCA I involvedin the pathogenesisorprogression of bothtypesof adenocarcinoma.OtherrecentstudiestestedforLOHat 5q2I (APC), 3 ~ 2 1 , 9p21 (CDKN2A),and 17p13.1 (TP53)(Sanz-Ortegaet al., 2003; Suspiroet al., 2003). Sanz-

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Ortegaand collaboratorscomparedcases of BE adjacentto adenocarcinomaand cases of BE with no evidence of malignanttransformationduringa 5-10-year follow-up period. Frequentallelic losses wereseen in adenocarcinomas at TP53(54%), CDKN2A (50%),3p21 (40%), and 5q21 (33%). Most cases displayedidenticalLOH in the Barrett’sepithelium adjacentto the adenocarcinoma.LOH at these loci was rarely present in BE without evidence of malignanttransformation.However, in cases where sequentialendoscopic biopsies were performedin advanceof the adenocarcinomadiagnosis, LOH was already presentin the Barrett’sepithelium.It is conceivablethatLOHat theseloci is presentbefore the onset of the malignantproliferation,confirmingthe usefulnessof LOHanalysisor FISH analysis in supplementingthe histopathologicalevaluation of Barrett’sepithelium.The LOH at chromosomalbands3p21, 5q21,9p21, and 17p13 in cells of Barrett’sepithelium withoutdysplasiamight be useful markersfor individualswith a high risk of developing adenocarcinoma.

SUMMARY The most importanttumortype of the upperaerodigestivetractis squamouscell carcinomas of the head andneck. The nonrandomcytogeneticalterationsin these malignanttumorsare gains of 3q, 5p, 7p, 8q, 9q, 1 I q13, and 20q and losses of 3p, 5q, 8p, 9p, 1 I q, 13q, 18q, and 21q. Many of these same changes are seen in esophagealSCC. Several of the alterations havebeen associatedwith shorteneddisease-specificsurvivaland a poorclinicaloutcomein SCCHN, including3q gain, 7p gain, 8p loss, 1 I q13 amplification,and distal 1 Iq loss. The pooroutcomemay be a functionof therapeuticresistancedueto a particularconfigurationof oncogenesandtumorsuppressorgenes,as notedfor distal 1 1q loss. Manyof the othertumor typesin the upperaerodigestivetracthavenotbeenexaminedin sufficientnumbersto permit robustcorrelationsof cytogenetic biomarkerswith outcome. The cytogenetic findingsin upper aerodigestivetract tumors are now increasinglybeing placed into the context of biochemicalpathwaysin orderto understandhow the geneticalterationsin the tumorcells affect cell biology. The resultswill lead to more accuratediagnosis,prognosis,and patient selectionto identifythe optimaltreatmentfor each individualpatientas well as, ultimately, to better-targetedtherapiesbased on a detailedmolecularunderstandingof carcinogenesis in the head and neck region.

REFERENCES Agochiya M, Brunton VG, Owens DW, Parkinson EK, Paraskeva C, Keith WN, Frame MC (1999): Increased dosage and amplification of the focal adhesion kinase gene in human cancer cells. Oncogene 18:5646-5653. ,kervall JA, Michalides RJ, Mineta H, Balm A, Borg A, Dictor MR, Jin Y, Loftus B, Mertens F, Wennerberg JP (1997): Amplification of cyclin D1 in squamous cell carcinoma of the head and neck and the prognostic value of chromosomal abnormalities and cyclin D1 overexpression. Cancer 79:380-389. Albertson DG (2006): Gene amplification in cancer. Trends Genet 2 2 9 4 7 4 5 5 . Albertson DG, Collins C, McCormick F, Gray JW (2003): Chromosome aberrations in solid tumors. Nat Genet 34369-376.

400

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Aoki T, Mori T, Du X, NisihiraT, MatsubaraT, NakamuraY ( 1994):Allelotype study of esophageal carcinoma. Genes Chromosomes Cancer 10:177-1 82. Ashar HR, Fejzo MS. TkachenkoA, Zhou X, Fletcher JA, Weremowicz S, MortonCC. Chada K (1 995): Disruptionof the architecturalfactor HMGI-C: DNA-binding AT hook motifs fused in lipomas to distinct transcriptionalregulatorydomains. Cell 8 2 5 7 4 5 . BaldwinC, GarnisC, ZhangL, Rosin MP, Lam WL (2005):Multiplemicroalterationsdetectedat high frequency in oral cancer. Cancer Res 65:7561-7567. Bassing CH, Suh H, FergusonDO, ChuaKF, ManisJ, EckersdorlTM,Gleason M,BronsonR,Lee C, Ah F W (2003):Histone H2AX. a dosage-dependentsuppressorof oncogenic translocationsand tumors. Cell 114:359-370. Beder LB, GunduzM, Ouchida M, FukushimaK, GunduzE, It0 S,Sakai A, Nagai N, Nishizaki K, Shimizu K (2003):Genome-wideanalyses on loss of heterozygosity in head and neck squamous cell carcinomas.Lab Invest 83:99-105. Behboudi A, EnlundF,Winnes M, And& Y, NordkvistA, Leivo 1, FlabergE, Szekely L, MakitieA, Grenman R, Mark J, Stenman G (2006):Molecular classification of mucoepidermoidcarcinomas-prognostic significance of the MECTI -MAML2 fusion oncogene. Genes Chromosomes Cancer 45:470-48 1. Beuzen F, Dubois S, FlejouJF(2000):Chromosomalnumericalaberrationsarefrequentin oesophageal and gastric adenocarcinomas:a study using in-situ hybridization.Histopathology 37:241-249. Bockmuhl U, Wolf G, Schmidt S, Schwendei A, JahnkeV, Dietel M, Petersen I (1998):Genomic alterationsassociated with malignancy in head and neck cancer. Head Neck 20:145-15 1. Bockmuhl U, lshwad CS, Ferrell RE, Collin SM (2001):Association of 8p23 deletions with poor survival in head and neck cancer. Otolaryngol Head Neck Surg 124: 451455. Bockmuhl U, You X, Pacyna-GengelbachM, Arps H, Draf W, Petersen 1 (2004):CGH patternof esthesioneuroblastomaand their metastases. Brain Pathol 14: 158- 163 Braakhuis BJ, Leemans CR, BrakenhoffRH (2004):A genetic progression model of oral cancer: currentevidence and clinical implications. J Oral Pathol Med 33:3 17-322. Brzoska PM, Levin NA, Fu KK, KaplanMJ, Singer MI, Gray JW, ChristmanMF (1995):Frequent novel DNA copy number increase in .quamous cell head and neck tumors. Cancer Res 55:3055-3059. Bullerdiek J, Raabe G, BartnitzkeS, Boschen C, Schloot W, BullerdiekJ, Raabe G, BartnitzkeS, Boschen C, Schloot W (1987):Structuralrearrangementsof chromosomeNr 8 involving 8q 12-a primaryevent in pleomorphic ademona of the parotidgland. Genetica 72%-92. BullerdiekJ, Chilla R, HaubrichJ, MeyerK, BartnitzkeS, BullerdiekJ, ChillaR, HaubrichJ, MeyerK, BartnitzkeS (1 988a):A causal relationshipbetween chromosomalrearrangementsandthe genesis of salivary gland pleomorphicadenomas.Arch Oto Rhino Laryngol245:244-249. Bullerdiek J, HaubrichJ, Meyer K, BartnitzkeS (1988b):Translocationt(11;19)(q21;p13,1)as the sole chromosome abnormalityin a cystadenolymphoma(Warthin’stumor)of the parotidgland. Cancer Genet Cytogenel35:129-132. Bullerdiek J, Wobst G, Meyer-Bolte K, Chilla R, Haubrich J, Thode B, Bartnitzke S (1993): Cytogenetic subtypingof 220 salivary glandpleomorphicadenomas:correlationto occurrence, histological subtype, and in vitro cellular behavior. Cancer Genet Cytogenet 65:27-31. CalifanoJ, van derRiet P, WestraW, Nawroz H, ClaymanG, PiantadosiS, Con0 R, Lee D, Greenberg B, Koch W, DidranskyD ( 1 996):Geneticprogressionmodel for headandneck cancer:implications for field cancerization.Cancer Res 56:2488-2492. Califano J, Koch W, SidranskyD, WestraWH (2000a):Invertedsinonasal papilloma: a molecular genetic appraisalof its putative status as a precursorto squamouscell carcinoma.Am J Pathol 156~333-337.

REFERENCES

401

Califano J, Westra WH, Meininger G, Corio R, Koch WM, Sidransky D (2000b): Genetic progressionand clonal relationshipof recurrentpremalignanthead and neck lesions. Clin Cancer Res 6:347-352. Castaneda VL, Cheah MS, Saldivar VA, Richmond CM, Parmley RT (1991):Cytogenetic and molecular evaluation of clinically aggressive esthesioneuroblastoma.Am J Pediatr Hematol Oncol I3:62-70. Celeste A, DifilippantonioS, DifilippantonioMJ, Fernandez-Capetillo0,Pilch DR, SedelnikovaOA, Eckhaus M, Ried T, Bonner WM, Nussenzweig A (2003): H2AX haploinsufficiency modifies genomic stability and tumor susceptibility. Cell 1 14371-383. Cerilli LA, SwartzbaughJR, SaadutR, MarshallCE, RumpelCA, MoskalukCA, FriersonHF (1999): Analysis of chromosome9p2 1 deletion and p 16gene mutationin salivaryglandcarcinomas.Hum Pathol30:1242-1246. ChanAS, To KF, Lo KW, Mak W,Pak W, Chiu B, Tse GM, Ding M, Li X, Lee JC, Huang DP (2000): High frequency of chromosome 3p deletion in histologically normal nasopharyngealepithelia from southernChinese. Cancer Res 605365-5370. Chan AS, To KF, Lo KW, Ding M, Li X,Johnson P, Huang DP (2002): Frequentchromosome9p losses in histologically normal nasopharyngealepithelia from southernChinese. Int J Cancer 102:300-303. Chen YJ, KOJY, Chen PJ, Shu CH, Hsu MT, Tsai SF, Lin CH (1999): Chromosomalaberrationsin nasopharyngealcarcinomaanalyzedby comparativegenomic hybridization.Genes Chromosomes Cancer 25: 169-175. Chow LS, Lo KW, KwongJ, To KF,Tsang KS, LamCW, DammannR, HuangDP (2004): RASSFlA is a targettumorsuppressorfrom 3p2 1.3 in nasopharyngealcarcinoma.Znt J Cancer 109:839-8447. ChungCH, Ely K, McGavranL, Varella-GarciaM, ParkerJ, ParkerN, JarrettC, CarterJ, MurphyBA, Netterville J, Burkey BB, Sinard R, Cmelak A, Levy S, YarbroughWG, Slebos RJ, Hirsch FR (2006): lncreased epidermalgrowth factor receptorgene copy number is associated with poor prognosis in head and neck squamouscell carcinomas. J Clin Oncol24:41704176. Ciullo M, Debily MA, Rozier L, Autiero M, Billault A, Mayau V, El Marhomy S, Guardiola1, BernheimA, Coullin P, Piatier-TonneauD, Debatisse M (2002): Initiationof the breakage-fusionbridgemechanismthroughcommon fragile site activationin humanbreastcancercells: the model of PIP gene duplication from a break at FRA71. Hum Mol Genet 1 I :2887-2894. Claudio PP, HowardCM, Fu Y, Cinti C, Califano L, Micheli P, Mercer EW, Caputi M, GiordanoA (2000): Mutations in the retinoblastoma-relatedgene RB2/p I30 in primary nasopharyngeal carcinoma. Cancer Res 60:8-12. Collins C. RommensJM, Kowbel D, GodfreyT, TannerM, Hwang SI, Polikoff D, Nonet G, Cochran. J, Myambo K, Jay KE, Froula J, Cloutier T, Kuo WL, Yaswen P, Dairkee S, Giovanola J, Hutchinson GB, Isola J, Kallioniemi OP, Palazzolo M, Martin C, Ericsson C, Pinkel D, Albertson D, Li WB, Gray JW (1998): Positional cloning of ZNF217 and NABC1: genes amplified at 20q13.2 and overexpressed in breast carcinoma. Proc Natl Acad Sci USA 95:8703-8708. CowanJM (1 992): Cytogeneticsin head andneck cancer.Otolaryngol Clin North Am 25: 1073-1087. Debiec-Rychter M, Van ValckenborghI, Van den Broeck C, HagemeijerA, Van de Ven WJ, Kas K, Van Damme B, Voz ML (2001): Histologic localization of PLAG1 (pleomorphicadenomagene 1) in pleomorphic adenoma of the salivary gland: cytogenetic evidence of common origin of phenotypically diverse cells. Lab Invest 8 1 :1289-1297. Dinjens WN, KoppertLB, Dezentje DA, Abbou M, van Ballegooijen ES, Sleddens HF, van Dekken H, Tilanus H W , Wijnhoven BP (2006): Identification of a 7.1-mega base pairs minimal deletion at 14q31.1-32.11 in adenocarcinomasof the gastroesophagealjunction. Hum Pathol 37536541.

402

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Dolan K, GardeJ, WalkerSJ, SuttonR, Gosney J, Field JK (1999): LOHat the sites of the DCC, APC, and TP53 tumor suppressor genes occurs in Barrett’s metaplasia and dysplasia adjacent to adenocarcinomaof the esophagus. Hum Puthol30: 1508- 15 14. Dolan K, Moms AI,Gosney JR, Field JK,SuttonR, Dolan K, MorrisAI, Gosney JR, Field JK, Sutton R (2003): Loss of heterozygosity on chromosome 17ppredicts neoplastic progressionin Barrett’s esophagus. J Gastroenterol Hepatol 18:683-689. DSouza G,KreimerAR, Viscidi R, Pawlita M, FakhryC, Koch WM, Westra WH. Gillison ML (2007): Case-control study of human papillomavirusand oropharyngealcancer. N Engl J Med 356: 1944-1956. Du Plessis L,Dietzsch E, Van Gele M, Van Roy N, Van HeldenP, ParkerMI, MugwanyaDK, De Groot M, Marx MP, Kotze MJ, SpelemanF (1999): Mappingof novel regions of DNA gain and loss by comparativegenomic hybridizationin esophageal carcinomain the Black andColoredpopulations of South Africa. Cancer Res 59:1877- 1883. DurkinSG, Glover TW (2007): Chromosomefragile sites. Annu Rev Genet 41:169-192. El-Naggar AK, Lovell M, Killary AM, Clayman GL, Batsakis JG (19%): A mucoepidermoid carcinomaof minor salivary gland with t( I I ;19)(q2I ;p13.I ) as the only karyotypicabnormality. Cancer Genet Cytogenet 87:29-33. El-Naggar AK, Abdul-Karim FW, Hurr K, Callender D. Luna MA, Batsakis JG (1998): Genetic alterationsin acinic cell carcinomaof the parotidgland determinedby microsatellite analysis. Cancer Genet Cytogenet 102:19-24. El-NaggarAK, Lovell M, CallenderDL, OrdonezNG, Killary AM (1999): Cytogeneticanalysis of a primarysalivary gland myoepithelioma. Cancer Genet Cytogenet 1 13:49-53. El-Rifai W,RutherfordS, KnuutilaS, FriersonHFJr,MoskalukCA (2001): Novel DNA copy number losses in chromosome I2ql2-q I3 in adenoid cystic carcinoma.Neoplasia 3: 173-1 78. Enlund F, Behboudi A, And& Y,ObergC, Lendahl U, Mark J, StenmanG (2004): Altered Notch signaling resulting from expression of a WAMTPl-MAML2 gene fusion in mucoepidermoid carcinomasand benign Warthin’stumors. Exp Cell Res 2 9 2 2 1-28. Forastiere A, Koch W, Trotti A, Sidransky D (2001): Head and neck cancer. N Engl J Med 345:1890-1900. FracchiollaNS, PruneriG, PignatamL, CarboniN, CapaccioP, Boletini A, Buffa R, Neri A (1997): Molecularand immunohistochemicalanalysis of the bcl- l/cyclin D1 gene in laryngealsquamous cell carcinomas: correlationof protein expression with lymph node metastases and advanced clinical stage. Cancer 79: I 1 1 4 - 1 121. FreierK, FlechtenmacherC, WalchA, Oh1S, Devens F, BurkeB, Hassfeld S, LichterP, Joos S,Hofele C (2005): Copy numbergains on 22ql3 in adenoidcystic carcinomaof the salivarygland revealed by comparativegenomic hybridizationand tissue microarrayanalysis. Cancer Genet Cytogenet 159:89-95. Freier K, Sticht C, Hofele C, FlechtenmacherC, Stange D, Puccio L, Toed1G , RadlwimmerB, Lichter P, Joos S (2006): Recurrentcoamplification of cytoskeleton-associated genes EMS I and SHANK2 with CCNDl in oral squamous cell carcinoma. Genes Chromosomes Cancer 45:118-125. FreierK, SchwaenenC, Sticht C, FlechtenmacherC, MuhlingJ, Hofele C, RadlwimmerB, LichterP, Joos S (2007): Recurrent FGFRl amplification and high FGFRl protein expression in oral squamouscell carcinoma(OSCC). Oral Oncol43:60-66. Gibcus JH, Kok K, Menkema L, HermsenMA, Mastik M, Kluin PM, van der Wal JE, SchuuringE (2007a): High-resolution mapping identifies a commonly amplified 1 1q 13.3 region containing multiple genes flanked by segmental duplications.Hum Genet 121: 187-201. Gibcus JH. Menkema L, Mastik MF, Hermsen MA, de Bock GH, van Velthuysen ML, Takes RP, Kok K, Alvarez Marcos CG van der Laan BF, van den Brekel MW, LangendijkJA, Kluin PM,

REFERENCES

403

van derWalJE,SchuuringE (2007b): Amplicon mappingandexpressionprofilingidentify the Fasassociated death domain gene as a new driver in the I lq13.3 amplicon in laryngeaypharyngeal cancer. Clin Cancer Res 13:6257-6266. Gil Z, Orr-UrtregerA, Voskoboinik N, Trejo-LeiderL, Spektor S, ShomratR, Fliss DM (2006): Cytogenetic analysis of sinonasal carcinomas. Otolaryngol Head Neck Surg 134:654-660. Gleeson CM, Sloan JM, McGuigan JA, Ritchie AJ. Weber JL, Russell SE (1998): Barrett’s oesophagus: microsatellite analysis provides evidence to support the proposed metaplasiadysplasia-carcinomasequence. Genes Chromosomes Cancer 2 1 :49-60. Collin SM (2001): Chromosomal alterationsin squamous cell carcinomasof the head and neck: window to the biology of disease. Head Neck 23:238-353. Gollin SM (2005): Mechanismsleading to chromosomal instability.Semin Cancer 3iol 1k33-42. Collin SM, Janecka IP (1994): Cytogenetics of cranial base tumors.J Neurooncol20:3 241-254 Gotte K, Riedel F, Coy JF, Spahn V,HormannK (2000): Salivarygland carcinosarcoma:immunohistochemical, molecular genetic and electron microscopic findings. Oral Oncol36:36&364. Gotte K, GanssmannS, Affolter A, SchaferC, Riedel F, Arens N, FingerS , HonnannK (2005): Dual FISH analysis of benign and malignanttumorsof the salivaryglandsandparanasalsinuses. Oncol Reports 14:1103-1107. Guan Z , Wang XR, Zhu XF, HuangXF, Xu J, Wang LH, WanXB, Long ZJ,Liu JN, Feng GK, Huang W, Zeng YX, Chen FJ,Liu Q (2007): Aurora-A,a negative prognosticmarker,increasesmigration and decreases radiosensitivityin cancer cells. Cancer Res 67: 10436-10444. Hage M, SiersemaPD, Vissers KJ, DinjensWN, SteyerbergEW,HaringsmaJ, KuipersEJ,van Dekken H (2006): Genomic analysis of Barrett’sesophagus after ablative therapy:persistence of genetic alterationsat tumor suppressorloci. lnt J Cancer 118:155-160. HarperLJ, Piper K, Common J, FortuneF, Mackenzie IC (2007): Stem cell patternsin cell lines derived from head and neck squamous cell carcinoma.J Oral Pathol Med 36:594-603. Heinrich UR, Brieger J, Gosepath J, Wierzbicka M, Sokolov M, Roth Y, Szyfter W, Bittinger F, Mann WJ (2007): Frequent chromosomalgains in recurrentjuvenile nasopharyngealangiofibroma. Cancer Genet Cytogenet 175:138-143. HellmanA, ZlotorynskiE,SchererSW.CheungJ,VincentJB,SmithDl,TrakhtenbrotL, KeremB(2002): A role forcommonfragile site inductionin amplificationof humanoncogenes. Cancer Cell 1 :89-97. HermsenMA, Joenje H, ArwertF, BraakhuisBJ, BaakJP,WesterveldA, SlaterR ( 1 997): Assessment of chromosomal gains and losses in oral squamous cell carcinoma by comparativegenomic hybridisation. Oral Oncol33:414-4 18. HermsenM, SnijdersA. GuervosMA, TaenzerS, KoemerU, BaakJ, PinkelD, AlbertsonD, van Diest P, Meijer G, Schriick E (2005): Centromericchromosomal translocationsshow tissue-specific differences between squamouscell carcinomasand adenocarcinomas.Oncogene 24: 1571- 1579. Heselmeyer K, Macville M,Schrock E, Blegen H, Hellstrom AC, Shah K, Auer G, Ried T (1 997): Advanced-stagecervicalcarcinomasare definedby a recurrentpatternof chromosomalabemations revealing high genetic instability and a consistent gain of chromosomearm 3q. Genes Chromosomes Cancer 19~233-240. Hibi K, TrinkB, PatturajanM, WestraWH, CaballeroOL, Hill DE, RatovitskiEA, Jen J, SidranskyD (2000): A H is an oncogene amplified in squamous cell carcinoma. froc Nut1 Acad Sci USA 9715462-5467. Holland H. Koschny R, Krupp W, Meixensberger J, Bauer M, Kirsten H, Ahnert P (2007): Comprehensivecytogenetic characterizationof an esthesioneuroblastoma.Cancer Genef Cytogenet 173:89-96. HonjoN, GunduzM, FukushimaK, Cengiz B, BederLB, GunduzE, NagatsukaH,Xiao J, ShimizuK, Nishizaki K (2007): Comprehensiveloss of heterozygosity analysis and identificationof a novel hotspot at 3p21 in salivary gland neoplasms. Otolaryngol Head Neck Surg 137:1 19-125.

404

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Horsman DE, Berean K, DurhamJS (1995): Translocation(1 I ;19)(q21;p13. I ) in mucoepidemoid carcinomaof salivary gland. Cancer Genet Cytogenet 80:165-1 66. Hu N, Roth MJ, PolymeropolousM, TangZZ, Emmert-BuckMR, WangQH, GoldsteinAM, Feng SS, Dawsey SM, Ding T, ZhuangZP, Han XU, Ried T, Giffen C, TaylorPR (2000): Identificationof novel regions of allelic loss froma genomewide scan of esophageal squamous-cellcarcinomain a high-risk Chinese population. Genes Chromosomes Cuncer27:2 17-228. Huang DP, Ho JH, ChanWK, Lau WH, Lui M (1989): Cytogeneticsof undifferentiatednasopharyngeal carcinomaxenograftsfrom southernChinese. Inr J Cancer 43936-939. HuangX, Gollin SM, RajaS,GodfreyTE(2002): High-resolutionmappingof the 1 Iq 13ampliconand identificationof a gene, TAOSI, thatis amplifiedandoverexpressedin oral cancercells. Proc Nut1 Acad Sci USA 99: I 1369-1 1374. HuangX, GodfreyTE, GoodingWE, McCartyKS Jr, Gollin SM (2006): Comprehensivegenome and transcriptomeanalysis of the I lq13 amplicon in human oral cancer and synteny to the 7F5 amplicon in murine oral carcinoma.Genes ChromosomesCancer 45: 105% 1069. Hui AB, Lo KW, Leung SF. Teo P, Fung MK, To KF, Wong N, Choi PH, Lee JC, HuangDP (1 999): Detection of recurrentchromosomal gains and losses in primarynasopharyngealcarcinomaby comparativegenomic hybridisation.Int J Cancer 82:498-503. Hui AB, OrYY, TakanoH, TsangRK, To KF, GuanXU, ShamJS, Hung KW, LamCN, van HasseltCA, Kuo WL, Gray JW,Huang DP, Lo KW (2005): Array-basedcomparativegenomic hybridization analysis identifiedcyclin D1 as a targetoncogene at I 1q 13.3 in nasopharyngealcarcinoma.Cancer Res 65:8 125-8 1 33. HungermannD, Roeser K, BuergerH, Jake1T, Loning T, HerbstH (2002): Relative paucityof gross genetic alterationsin myoepithcliomasand myoepithelialcarcinomasof salivaryglands.JPuthol 198:487494. Ishii H, Mimori K, Inoue H, InagetaT, IshikawaK, Semba S, DruckT, TrapassoF, Tani K, Vecchione A, Croce CM, Mori M, HuebnerK (2006): Fhit modulatesthe DNA damagecheckpointresponse. Cancer Res 66:1 1287- 1 I 292. Ishii H, Wang Y,HuebnerK (2007): A Fhit-ing role in the DNA damage checkpoint response. Cell Cycle 6: 1044-1048. Ishwad CS, Ferrell RE, Rossie KN, Appel BN, Johnson JT, Myers EN, Law JC, SrivastavaS, Gollin SM (1996): Loss of heterozygosity of the short arm of chromosomes 3 and 9 in oral cancer.fnt J Cancer 69: 1-4. IshwadCS, ShusterM, Bockmuhl U, ThakkerN, Sh& P, Toomes C, Dixon M, FerrellRE, Gollin SM ( 1999):Frequentallelic loss andhomozygousdeletion in chromosomeband8p23 in oralcancer.f n t J Cancer 80:25-3 1. lzzo JG, PapadimitrakopoulouVA, Li XQ, Ibarguen H, Lee JS, Ro JY, El-Naggar A, Hong WK, HittelmanWN ( I 998): Dysregulatedcyclin DI expressionearlyin headandneck tumorigenesis:in viva evidence for an association with subsequentgene amplification. Oncogene 17:2313-2322. JacquemontC, TaniguchiT (2007): The Fanconi anemiapathway and ubiquitin. BMC Biochem 8 (Suppl I): s10. JaresP,FemandezPL, CampoE, Nadal A, Bosch F, Aiza G, Nayach 1, Trase.rraJ, CardesaA (1994): PRAD- I/cyclin D 1 gene amplificationcorrelateswith messenger RNA overexpressionand tumor progression in human laryngeal carcinomas.Cancer Res 54:48 13-481 7. JarvinenAK, Autio R, Haapa-PaananenS, Wolf M, SaarelaM,GrenmanR, Leivo I, Kallioniemi 0, Makitie AA, Monni 0 (2006): Identification of target genes in laryngeal squamous cell carcinomaby high-resolution copy numberand gene expression microarrayanalyses. Oncogene 25 ~6997-7008. JeannonJP, Wilson JA ( 1998): Cyclins, cyclin-dependentkinases, cyclin-dependentkinase inhibitors and their role in head and neck cancer. Clin Otoluryngol Allied Sci 23:420-424.

REFERENCES

405

JemalA, Siege1R, WardE, MurrayT,Xu J,ThunMJ(2007):Cancerstatistics,2007. CA Cancer J Clin 57:43-66. Jin YS.Higashi K, MandahlN, Heim S, WennerbergJ, BiorklundA, DictorM, MitelmanF (1990): Frequentrearrangementof chromosomalbands lp22 and 1 lq13 in squamouscell carcinomasof the head and neck. Genes Chromosomes Cancer 2:198-204. Jin Y, MertensF, Arheden K, MandahlN, WennerbergJ, Dictor M, Heim S, MitelmanF (1995a): Karyotypicfeaturesof malignanttumorsof the nasal cavity and paranasalsinuses. fnt J Cancer 60:637-641. JinY,MertensF, MandahlN, WennerbergJ, DictorM, HeimS, MitelmanF (1995b):Tetraploidization and progressiveloss of 6q in a squamouscell carcinomaof the parotidgland. Cancer Genet Cytogenel 79: 157-159. JinC, Jin Y, WennerbergJ, kervallJ, DictorM, MandahlN, Heim S, MitelmanF,MertensF (1997): Cytogenetic analysis of invertednasal papillomasand demonstrationof genetic convergence duringin vitro passaging.Int J Cancer 70:668-673. Jin C, Jin Y, HoglundM, WennerbergJ, hervall J, Willen R, Dictor M,MandahlN, MitelmanF, MertensF ( 1 998a):Cytogeneticand moleculargeneticdemonstrationof polyclonalityin an acinic cell carcinoma.Br J Cancer 78:292-295. Sin Y, Hoglund M, Jin C, Martins C, WennerbergJ, hervall J, Mandahl N, Mitelman F, Mertens F (1998b): FISH characterizationof head and neck carcinomas reveals that amplificationof band llq13 is associated with deletion of distal 1 lq. Genes Chromosomes Cancer 22:31 2-320. Jin Y, Jin C, WennerbergJ, MertensF, Hoglund M (1998~):Cytogeneticand fluorescencein situ hybridizationcharacterizationof chromosome 1 rearrangementsin head and neck carcinomas delineatea target region for deletions within lpll-lp13. Cancer Res 585859-5865. Jin C, MartinsC, Jin Y,WiegantJ, WennerbergJ, DictorM, GisselssonD, Str6mbeckB, Fonseca 1, MitelmanF, TankeHJ, HoglundM, MertensF (2001): Characterization of chromosomeaberrationsin salivaryglandtumorsby FISH,includingmulticolorCOBRA-FISH.Genes Chromosomes Cancer 30:161-167. Jin C, Jin Y,Gisselsson D, WennerbergJ, Wah TS, StrombackB, Kwong YL, MertensF (2006a): Molecularcytogenetic characterizationof the 1 l q 13 ampliconin head and neck squamouscell carcinoma.Cytogenet Genome Res 115:99-106. JinC, Jin Y, WennerbergJ, AMWZK,EnokssonJ, MertensF (2006b): Cytogeneticabnormalitiesin 106 oral squamouscell carcinomas.Cancer Genet Cytogenet 164:44-53. KalyankrishnaS, GrandisJR (2006): Epidermalgrowth factorreceptorbiology in head and neck cancer.J Clin Oncol24:2666-2672. KanazawaT,IwashitaT,KommareddiP, Nair T, Misawa K, Misawa Y, Ueda Y,Tono T, CareyTE (2007): Galaninandgalaninreceptortype 1 suppressproliferationin squamouscarcinomacells: activationof the extracellularsignal regulatedkinasepathwayand inductionof cyclin-dependent kinase inhibitors.Oncogene 265762-5771. KandasamyJ, Smith A, Diaz S, Rose B, OBrien C (2007): Heterogeneityof PLAGI gene rearrangementsin pleomorphicadenoma.Cancer Genet Cytogenet 177:1-5. Kas K,Roijer E, Voz M, Meyen E, StenmanG, Van de Ven WJ (1997a): A 2-Mb YAC contig and physicalmapcoveringthe chromosome8ql2 breakpointclusterregionin pleomorphicadenomas of the salivaryglands. Genomics 43:349-358. Kas K, Voz ML, Roijer E, Astrom AK, Meyen E, StenmanG, Van de Ven WJ (1997b): Promoter \wapping between the genes for a novel zinc finger protein and beta-cateninin pleiomorphic adenomaswith t(3;8)(p21;q12) translocations.Nut Genet 15:170-174. KirchhoffM, Rose H, PetersenBL, MaahrJ,GerdesT, LundsteenC, BryndorfT,Kryger-BaggesenN, ChristensenL, Engelholm SA, Philip J (1999): Comparativegenomic hybridizationreveals a

406

TUMORS OF THE UPPER AERODIGESTIVE TRACT

recurrentpatternof chromosomalaberrationsin severe dysplasidcarcinomain situ of the cervix and in advanced-stagecervical carcinoma.Genes ChromosomesCancer 24: 144-1 50 Korinth D, Pacyna-Gengelbach M, Deutschmann N, HattenbergerS, Bockmuhl U, Dietel M, SchroederHG,DonhuijsenK, Petersen I (2005): Chromosomalimbalancesin wood dust-dated adenocarcinomasof the innernose and their associations with pathologicalparameters.J Pathol 2071207-2 15. Kwong D, Lam A, Guan X, Law S, Tai A, Wong J, Sham J (2004): Chromosomalaberrationsin esophageal squamouscell carcinomaamong Chinese: gain of 12p predicts poor prognosis after surgery.Hum Pathol35:309-316. Lo KW, Huang DP (2002): Genetic and epigenetic changes in nasopharyngealcarcinoma.Semin CancerBiol 12:451 4 6 2 Lo KW, Huang DP, Lau KM ( 1 995):p16 gene alterationsin nasopharyngealcarcinoma.CancerRes 55~2039-2043. Lo KW, Teo PM, Hui AB, To KF, Tsang YS,Chan SY.Mak KF, Lee JC, Huang DP (2000): High resolution allelotype of microdissected primary nasopharyngeal carcinoma. Cancer Res m3348-3353. Lo KW, Tsang YS,Kwong J, To KF, Teo PM, Huang DP (2002): Promoterhypermethylationof the EDNRB gene in nasopharyngealcarcinoma. fnt J Cancer98:651-655. Lo Muzio L, Campisi G, FarinaA, RubiniC, PastoreL, GiannoneN, Colella G, LeonardiR, CarinciF (2007): Effect of p63 expression on survival in oral squamous cell carcinoma. Cancer Invest 25:464-469. Lobachev KS, Gordenin DA, Resnick MA (2002): The Mrel 1 complex is requiredfor repairof hairpin-capped double-strand breaks and prevention of chromosome rearrangements.Cell 108:183-1 93. MaestroR, GasparottoD, VukosavljevicT, BarzanL, Sulfaro S, Boiocchi M (1993): Threediscrete regions of deletion at 3p in head and neck cancers. Cancer Res 535775-5779. Mahlamaki EH. Barlund M, TannerM, Gorunova L, Hoglund M, KarhuR, Kallioniemi A (2002): Frequentamplification of 8q24, 1 Iq, 17q, and 20q-specific genes in pancreaticcancer. Genes ChromosomesCancer35~353-358. MarkJ, SandrosJ. Wedell B, StenmanG, EkedahlC (1 988): Significanceof the choice of tissue culture technique on the chromosomal patternsin human mixed salivary gland tumors. Cancer Genet Cytogenet 33:229-244. MarkJ, DahlenforsR, StenmanG, NordquistA ( 1989):A humanadenolymphomashowingthe chromosomal aberrationsdel (7)(p12p14-15) and t( 11;19)(q21;p12-13). AniicancerRes 9:1565-1566. MarkJ, DahlenforsR, StenmanG, NordquistA (1990): Chromosomalpatternsin Warthin’stumor.A second type of human benign salivary gland neoplasm. Cancer Genet Cytogenet 46:35-39. MartinCL, Reshmi SC, Ried T, GottbergW, Wilson JW, ReddyJK, KhannaP, JohnsonJT,MyersEN, Collin SM (2008): Chromosomalimbalancesin oral squamouscell carcinoma:Examinationof 3 I cell lines and review of the literature.OralOncoZ44:369-382. MartinsC, Fonseca I, Roque L, Pinto AE, Soares J (1 996): Malignant salivary gland neoplasms:a cytogenetic study of 19 cases. EurJ Cancer. 32B:128-332. MartinsC, Fonseca I, Roque L, Soares J ( I 997): Cytogenetic characterisationof Warthin’stumour. Oral Oncol33:344-347. MartinsC, Fonseca 1, RoqueL, RibeiroC, SoaresJ (2001): Cytogenetic similaritiesbetweentwo types of salivary gland carcinomas:adenoidcystic carcinomaand polymorphouslow-grade adenocarcinoma. CancrrGenet Cytogenrl 128:130-1 36. Menke-PluymersMB, van Drunen E, Vissers KJ, Mulder AH, Tilanus HW, HagemeijerA ( 1996): Cytogeneticanalysisof Barrett’smucosa and adenocarcinomaof the distal esophagus andcardia. Cancer Genet Cytogenet 90: 109-1 17.

REFERENCES

407

MerrittWD, Weissler MC, Turk BF, Gilmer TM (1990): Oncogene amplification in squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 116: 1394-1398. MertensF, JohanssonB. HoglundM, MitelmanF (1 997): Chromosomalimbalancemaps of malignant solid tumors:a cytogenetic survey of 3185 neoplasms. Cancer Res 57:2765-2780. MichalidesR,van Veelen N, Hart A, Loftus B, WientjensE, Balm A ( 1 995): Overexpressionof cyclin D1 correlateswith recurrencein a groupof forty-sevenoperablesquamouscell carcinomasof the head and neck. Cancer Res 55:975-978. Michalides RJ, van Veelen NM, Kristel PM, Hart AA, Loftus BM, Hilgers FJ, Balm AJ (1997): Overexpressionof cyclin D1 indicatesa poorprognosisin squamouscell carcinomaof the headand neck. Arch Otolaiyngol Head Neck Surg 123:497-502. MitelmanF, JohanssonB, MertensF, editors(2008): MitelmanDatabaseof ChromosomeAberrations in Cancer.Available at http://cgap.nci,nih.gov/Chromosomes/Mitelman. Montesano R, Hollstein M, Hainaut P (1996): Genetic alterationsin esophageal cancer and their relevance to etiology and pathogenesis: a review. Int J Cancer 69:225-235. MullerD, Millon R, TheobaldS, HussenetT, WasylykB, du ManoirS, Abecassis J (2006): Cyclin LI (CCNLI) gene alterationsin human head and neck squamous cell carcinoma. Br J Cancer 94:104 1-1 044.

NakashimaT, Pak SC, Silverman GA, Spring PM, FrederickMJ, Clayman GL (2000): Genomic cloning, mapping,structureandpromoteranalysis of HEADPIN,a serpinwhich is down-regulated in head and neck cancer cells. Biochim Biophys Acta 1492:44146. NarayananV, Mieczkowski PA, Kim HM, Petes TD, LobachevKS (2006): The patternof gene amplificationis determinedby the chromosomallocationof hairpincappedbreaks.Cell 125:1283-1 296. Nessling M, RichterK, SchwaenenC, Roerig P, WrobelG, WessendorfS, FritzB, Bentz M, Sinn HP, RadlwimmerB, LichterP (2005): Candidategenes in breastcancerrevealed by microarray-based comparativegenomic hybridizationof archived tissue. Cancer Res 65:439-447. Nordkvist A, Gustafsson H, Juberg-OdeM, Stenman G (1994a): Recurrent rearrangementsof I 1q14-22 in mucoepidemoid carcinoma.Cancer Genet Cytogenet 74:77-83. Nordkvist A, MarkJ, DahlenforsR, Bende M, Stenman G (1994b): Cytogeneticobservations in 13 cystadenolymphomas(Warthin’stumors). Cancer Genet Cytogenet 76: 129-135. Nordkvist A, Mark J, Gustafsson H, Bang G, Stenman G (1994~):Non-random chromosome rearrangementsin adenoid cystic carcinoma of the salivary glands. Genes Chromosomes Cancer 10:115-121. . Noutomi Y,Oga A, Uchida K, OkafujiM. Ita M, KawauchiS, FuruyaT, Ueyama Y,Sasaki K (2006): Comparativegenomic hybridizationreveals genetic progressionof oral squamouscell carcinoma from dysplasia via two different tumourigenicpathways. J Path012 10:67-74. Ogasawara S, Maesawa C, TamuraG, Satodate R (1995): Frequent microsatellite alterationson chromosome 3p in esophageal squamouscell carcinoma. Cancer Res 5589 1-894. Or YY,Hui AB, Tam KY,Huang DP, Lo KW (2005): Characterizationof chromosome3q and 12q amplicons in nasopharyngealcarcinomacell lines. fnt J Oncol26:49-56. Pack SD, KarkeraJD, ZhuangZ, Pak ED, Balan KV, Hwu P, ParkWS, Pham T, Auk DO, GlaserM, Liotta L, Detera-WadleighSD, Wadleigh RG ( 1999): Molecular cytogenetic fingerprintingof esophageal squamouscell carcinomaby comparativegenomic hybridizationreveals a consistent patternof chromosomalalterations.Genes ChromosomesCancer 25: 160-168. PanZG, KashubaVI, Liu XQ, Shao JY, Zhang RH, JiangJH, Guo C, ZabarovskyE, Ernberg1, Zeng YX (2005): High frequencysomaticmutationsin RASSFl A in nasopharyngealcarcinoma.Cancer Biol Ther 4 1 1 16- I 122. Pan C, Yan M, Yao J, Xu J, Long Z, HuangH. Liu Q (2008): Aurorakinase small molecule inhibitor destroys mitotic spindle, suppressescell growth, and induces apoptosis in oral squamouscancer cells. Oral Oncol44:639-645.

408

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Papadimitrakopoulou VA, Oh Y, El-NaggarA, 1220I, ClaymanG, MaoL (1998):Presenceof multiple incontiguousdeleted regions at the long arm of chromosome I8 in head and neck cancer.CIin Cancer Res 4539-544. ParikhRA, WhiteJS, HuangX,SchoppyDW, Baysal BE, BaskaranR, BakkenistCJ, SaundersWS, Hsu LC, RomkesM, GollinSM (2007):Lassof distal 1lq is associatedwith DNA repairdeficiency and reducedsensitivityto ionizing radiationin head and neck squamouscell carcinoma.Genes Chromosomes Cancer 46:761-775. ParkinDM, Bray F, Ferlay J, Pisani P (2005): Global cancer statistics,2002. CA Cancer J C h 5574-108. Patel V, Yeudall WA, GardnerA, Mutlu S, Scully C, Prime SS (1993): Consistentchromosomal anomaliesin keratinocytecell lines derivedfrom untreatedmalignantlesions of the oral cavity. Genes Chromosomes Cancer 7:109-115. PearlsteinRP,BenningerMS, CareyTE, ZarboRJ,TorresFX,RybickiBA, Dyke DL (1998):Loss of 18q predictspoor survivalof patientswith squamouscell carcinomaof the headand neck. Genes Chromosomes Cancer 2 1:333-339. PeraltaRC, Casson AG, Wang RN, KeshavjeeS, Redston M. Bapat B (1998): Distinct regions of frequentloss of heterozygosity of chromosome5p and 5q in humanesophagealcancer.Int J Cancer 78:60&605. PerroneF, Oggionni M, Birindelli S, Suardi S, Tabano S, Romano R, Moiraghi ML, Bimbi G, QuattroneP, CantuG, PierottiMA, LicitraL, PilottiS (2003):TP53,pl4ARF,p16INK4aandH-ras gene molecular analysis in intestinal-typeadenocarcinomaof the nasal cavity and paranasal sinuses. Znt J Cancer 105:196-203. PersonsDL, CroughanWS, Borelli KA, CherianR ( I 998): lnterphasecytogeneticsof esophageal adenocarcinomaand precursorlesions. Cancer Genet Cytogenet 106:11-17. Petty EM, Kalikin LM, OmngerMB, Beer DG (1998): Distal chromosome17q loss in Barrett’s esophagealandgastriccardiaadenocarcinomas: implicationsfor tumorigenesis.Mol Carcinogen 221222-228. Poeta ML, ManolaJ. GoldwasserMA, ForastiereA, Benoit N, CalifanoJA, Ridge JA, Goodwin J, KenadyD, SaundersJ, WestraW, SidranskyD, KochW M (2007):TP53 mutationsandsuMval in squamous-cellcarcinomaof the head and neck. N Engl J Med 357:2552-2561. QuintyneNJ, Reing JE,HoffelderDR, Gollin SM, SaundersWS (2005): Spindle multiplarityis preventedby centrosomalclustering.Science 307: 127- 129. RaginCC, Taioli E (2007): Survivalof squamouscell carcinomaof the head and neck in relationto humanpapillomavirusinfection:review and meta-analysis.Int J Cancer 121:1813- 1820. RaginCC,ReshmiSC, Gollin SM (2004): Mappingandanalysisof HPV 16 integrationsites in a head and neck cancercell line. Znt J Cancer 1 10:701-709. Ragin CC, Taioli E, Weissfeld JL, White JS, Rossie KM, ModugnoF, Gollin SM (2006): llq13 amplificationstatusand humanpapillomavirusin relationto p16 expressiondefines two distinct etiologies of head and neck turnours.Br J Cancer 95:1432-1438. Rao PH, Murty VV, Louie DC, ChagantiRS (1998): Nonsyntenic amplificationof MYC with CDK4 and MDM2 in a malignant mixed tumor of salivary gland. Cancer Genet Cytogenet 105:16Ck163. RedonR, HussenetT, BourG, CauleeK, JostB, MullerD, AbecassisJ, du ManoirS (2002):Amplicon mappingand transcriptional analysispinpointcyclin L as a candidateoncogenein headandneck cancer. Cancer Res 62:6211-6217. Reid BJ. Prevo LJ, GalipeauPC, SanchezCA, LongtonG, Levine DS, Blount PL, RabinovitchPS (2001): Predictorsof progressionin Barrett’sesophagus11: baseline 17p (p53) loss of heterozygosity identifiesa patientsubsetat increasedrisk for neoplasticprogression.Am J Gastroenterol 96~2839-2848.

REFERENCES

409

RennstamK, Ahlstedt-Soini M, BaldetorpB. Bendahl PO, Borg KarhuR, TannerM, TirkkonenM, Isola J (2003): Patterns of chromosomal imbalances defines subgroups of breast cancer with distinct clinical features and prognosis. A study of 305 tumorsby comparativegenomic hybridization. Cancer Res 6323861-8868. Reshmi SC, SaundersWS, Kudla DM,Ragin CR, Gollin SM (2004): Chromosomalinstability and markerchromosome evolution in oral squamous cell carcinoma. Genes Chromosomes Cancer 41 :3846. Reshmi SC, Huang X, Schoppy DW, Black RC, Saunders WS, Smith DI, Gollin SM (2007a): Relationshipbetween FRAl IFand 1 Iql3 gene amplificationin oral cancer.Genes Chromosomes Cancer 4 6 143-154. ReshmiSC, RoychoudhuryS, Yu Z, FeingoldE, PotterD, SaundersWS, Gollin SM (2007b): Inverted duplicationpatternin anaphasebridges confirms the breakage-fusion-bridge(BFB)cycle model for I Iq 13 amplification.Cytogenet Genome Res 116:46-52. RichterTM, Tong BD, Scholnick SB (2005): Epigenetic inactivation and aberranttranscriptionof CSMDl in squamous cell carcinomacell lines. Cancer Cell Int 529. Roijer E, Kas K, BehrendtM, Van de Ven W, StenmanG (1 999): Fluorescencein situ hybridization mapping of breakpoints in pleomorphic adenomas with 8qI2-1 3 abnormalities identifies a subgroupof tumors without PLAG1 involvement. Genes Chromosomes Cancer 24:78-82. Roijer E, Nordkvist A, Striim AK, Ryd W, Behrendt M, Bullerdiek J, Mark J, Stenman G (2002): Translocation,deletiodamplification,and expression of HMGIC and MDM2 in a carcinomaex pleomorphicadenoma.Am J Path01 160:4334IO. Rosenberg PS, Greene MH, Alter BP (2003): Cancer incidence in persons with Fanconi anemia. Blood 101 :822-826. Rosenblum-VosLS, Meltzer SJ, Leana-Cox J, Schwartz S (1993): Cytogenetic studies of primary culturesof esophageal squamous cell carcinoma. Cancer Genet Cytogenet 70: 127-1 31. Rosin MP, Lam WL, Poh C, Le ND, Li RJ, Zeng T, PriddyR, ZhangL (2002): 3p14 and9p21 loss is a simple tool for predictingsecond oral malignancyat previously treatedoral cancer sites. Cancer Res 626447450. Rothschild BL, Shim AH, Ammer AG, Kelley LC, Irby KB, Head JA. Chen L, Varella-GarciaM, Sacks PG, Frederick B, Raben D. Weed SA (2006): Cortactinoverexpression regulates actinrelatedprotein2/3 complex activity, motility, andinvasionin carcinomaswith chromosome1 Iql3 amplification. Cancer R ~ . T66:8017-8025. Roz L, Wu CL, PorterS. Scully C, SpeightP, Read A, Sloan P,ThakkerN (1996): Allelic imbalanceon chromosome 3p in oral dysplastic lesions: an early event in oral carcinogenesis. Cancer Res 5 6 1228-1 23 1. RubinGrandisJ, Melhem MF, Gooding WE, Day R, Holst VA, WagenerMM, DrenningSD, Tweardy DJ ( 1998): Levels of TGF-alphaand EGFRproteinin headandneck squamouscell carcinomaand patient survival. J Natl Cancer lnst 90:824-832. Rumpel CA, Powell SM, Moskaluk CA (1999): Mapping of genetic deletions on the long arm of chromosome4 in human esophageal adenocarcinomas.Am J Pathol 154:1329-1 334. SaberAT, Nielsen LR, Dictor M. HagmarL, Mikoczy Z, WallinH (1 998): K-rasmutationsin sinonasal adenocarcinomas in patients occupationally exposed to wood or leather dust. Cancer Lett 12659-65. Samuels Y, Ericson K (2006): Oncogenic PI3K and its role in cancer. Curr Opin Oncol I8:77-82. SandrosJ, MarkJ, HapponenRP, StenmanG (1988): Specificity of 6s- markersand otherrecurrent deviations in human malignant salivary gland tumors. Anticancer Res k637-643. Sandros J, Stenman G, Mark J (1990): Cytogenetic and molecular observations in human and experimentalsalivary gland tumors.Cancer Genet Cytogenet 44:153- 167.

410

TUMORS OF THE UPPER AERODIGESTIVE TRACT

Sam-OrtegaJ, HernandezS, Saez MC, SierraE, Sanz-OrtegaG, TorresA, BalibreaJL,Sanz-Esponera J, Merino MJ (2003): 3p21, 5q21, 9p21 and 17~13.1allelic deletions are potential markersof individuals with a high risk of developing adenocarcinoma in Barrett’s epithelium without dysplasia. Hepatogastroenterology50:404-407. SarkariaI, Oc P,TalbotSG, Reddy PG, Ngai I, MaghamiE, Patel KN, Lee B, YonekawaY,DudasM, KaufmanA, Ryan R, Ghossein R, Rao PH, Stoffel A, RamanathanY,Singh B (2006): Squamous cell carcinomarelatedoncogene/DCUN 1D1 is highly conservedandactivatedby amplificationin squamouscell carcinomas. Cancer Res 66:9437-9444. Saunders WS, Shuster M, Huang X, GharaibehB, Enyenihi AH, Petersen I, Collin SM (2000): Chromosomalinstability and cytoskeletal defects in oral cancer cells. Proc Natl Acad Sci USA 97:303-308. SchoenmakersEF, WanschuraS, Mols R, Bullerdiek J, Van den Berghe H, Van de Ven WJ (1995): Recurrentrearrangementsin the high mobility group protein gene, HMGI-C, in benign mesenchymal tumours.Nat Genet 10:436-444. Scholnick SB, Richter TM (2003): The role of CSMDl in head and neck carcinogenesis. Genes Chromosomes Cancer 38:28 1-283. Shackney SE, Smith CA, Miller BW, Burholt DR, Murtha K, Giles HR, Ketterer DM, Pollice AA (1989): Model for the genetic evolution of human solid tumors. Cancer Res 49:3344-3354. ShellenbergerTD, MazumdarA, HendersonY,Briggs K, Wang M,ChattopadhyayC, JayakumarA, FrederickM, ClaymanGL (2005): Headpin:a serpinwith endogenousandexogenous suppression of angiogenesis. Cancer Res 651 1501-1 1509. Shih-kin Wu L (2006): Constructionof evolutionary tree models for nasopharyngealcarcinoma using comparativegenomic hybridizationdata. Cancer Genet Cytogenef 168:105-1 08. ShimadaM, YanagisawaA, Kato Y, Inoue M, Shiozaki H, MondenM, NakamuraY (1996): Genetic mechanismsin esophagealcarcinogenesis:frequentdeletionof 3p and 17p in premalignantlesions. Genes Chromosomes Cancer 15:165-1 69. Shiomi H, SugiharaH, KamitaniS . TokugawaT, TsubosaY, OkadaK, TamuraH, TaniT, KodamaM, Hattori T (2003): Cytogenetic heterogeneity and progression of esophageal squamous cell carcinoma. Cancer Genet Cytogenet 147:5@-61. ShusterMI, Han L, Le Beau MM, Davis E, Sawicki M, Lese CM, Park NH, Colicelli J, Collin SM (2000): A consistent patternof RINl rearrangementsin oral squamouscell carcinomacell lines supportsa breakage-fusion-bridgecycle model for I I q 13 amplification. Genes Chromosomes Cancer 28: 153-163. SlaughterDP, Southwick HW, Smejkal W (1953): Field cancenzation in oral stratifiedsquamous epithelium; clinical implications of multicentricorigin. Cancer 6963-968. SmithL, Liu SJ,GoodrichL, JacobsonD, Degnin C, Bentley N, CarrA, Flaggs G, KeeganK, Hoekstra M, Thayer MJ ( 1 998): Duplication of ATR inhibits MyoD, induces aneuploidy and eliminates radiation-inducedGI arrest.Naf Genet 1 9 3 9 4 6 . SnijdersAM, Schmidt BL, FridlyandJ, DekkerN, Pinkel D, JordanRC, AlbertsonDG (2005): Rare ampliconsimplicatefrequentderegulationof cell fate specificationpathwaysin oralsquamouscell carcinoma. Oncogene 24:4232-4242. Soder AI, HoareSF, Muire S, Balmain A, ParkinsonEK, Keith WN (1997): Mappingof the gene for the mouse telomerase RNA component,Terc,to chromosome3 by fluorescencein situ hybridization and mouse chromosomepainting. Genomics 4 I :293-294. SoderAI,Going JJ, Kaye SB, Keith WN, Soder Al. Going JJ, Kaye SB, Keith WN (1998): Tumour specific regulation of telomerase RNA gene expression visualized by in situ hybridization. Oncogene 16979-983.

REFERENCES

411

SparanoA, Quesnelle KM, KumarMS, WangY, SylvesterAJ, FeldmanM, Sewell DA, WeinsteinGS, Brose MS (2006): Genome-wide profiling of oral squamous cell carcinoma by array-based comparativegenomic hybridization.Laryngoscope 1 I6:735-74 I . Speicher MR, Howe C, Crotty P, du Manoir S, Costa J, Ward DC (1995): Comparativegenomic hybridizationdetects novel deletions and amplificationsin head and neck squamouscell carcinomas. Cancer Res 55:1010-1013. Spring P, Nakashima T, FrederickM, Henderson Y, Clayman G (1999): Identificationand cDNA cloning of headpin,a novel differentiallyexpressedserpinthatmapsto chromosome18q.Biochem Biophys Res Commun 264:299-304. Squire JA, Bayani J, Luk C, Unwin L, Tokunaga J, MacMillan C, Irish J, Brown D, Gullane P, Kamel-ReidS (2002): Molecularcytogenetic analysisof head andneck squamouscell carcinoma: By comparativegenomic hybridization,spectralkaryotyping,andexpressionarrayanalysis. Head Neck 242374-887. SreekantaiahC, Rao PH, Xu L, Sacks PG, SchantzSP, ChagantiRS (1994): Consistentchromosomal losses in head and neck squamouscell carcinomacell lines. Genes Chromosomes Cancer 1 1 :29-39. Stein CK, GloverTW, PalmerJL, Glisson BS (2002): Direct correlationbetween F7RA3B expression and cigarette smoking. Genes Chromosomes Cancer 34:333-340. StenmanG, SahlinP, MarkJ, ChagantiRS, KindblomLG,&an P ( 1993):The I2ql3-ql5 translocation breakpointsin pleomorphic adenoma and clear-cell sarcoma of tendons and aponeuroses are differentfrom that in myxoid liposarcoma.Genes ChromosomesCuncer 7:178- 180. Sticht C, Hofele C, FlechtenmacherC, Bosch FX, FreierK, LichterP, Joos S (2005): Amplificationof Cyclin L1 is associated with lymph node metastases in head and neck squamouscell carcinoma (HNSCC). Br J Cancer 92:770-774. Sun PC, Schmidt AP, Pashia ME, Sunwoo JB, Scholnick SB (1999): Homozygous deletionsdefine a region of 8p23.2 containinga putative tumor suppressorgene. Genornics 62: 184-1 88. Sun Q, SakaidaT.Yue W, Collin SM, Yu J (2007): Chemosensitizationof head and neck cancercells by PUMA. Mol Cancer Ther 6:3 180-31 88. SuspiroA, PereiraAD, Afonso A, AlbuquerqueC,Chaves P, Soares J. LeitaoCN (2003): Losses of heterozygosity on chromosomes !2p and 17p are frequent events in Barrett's metaplasia not associated with dysplasia or adenocarcinoma.Am J Gastroenterol98:728-734. Szymas J, Wolf G,Kowalczyk D, Nowak S, PetersenI (1997): Olfactoryneuroblastoma:detectionof genomic imbalancesby comparativegenomic hybridization.Acta Neurochir I 395339-844. Tada K, Oka M. Tangoku A, Hayashi H, Oga A, Sasaki K (2000): Gains of 8q23-qterand 20q and loss of 1 lq22-qterin esophageal squamouscell carcinomaassociated with lymphnode metastasis. Cancer 88:268-273. TakebayashiS, OgawaT,Jung KY, Muallem A, Mineta H, FisherSG, GrenmanR, CareyTE (2000): Identificationof new minimally lost regions on 18q in head and neck squamouscell carcinoma. Cancer Res 60:3397-3403. TakebayashiS, Hickson A, OgawaT, JungKY, MinetaH, Ueda Y,GrenmanR, FisherSG, CareyTE (2004): Loss of chromosomearm 18q with tumorprogressionin head andneck squamouscancer. Genes Chromosomes Cancer 41 :145-1 54. TanG, Chu Y,Chen J, Li H (2006): Genomic instabilityin the progressionof sporadicnasopharyngeal carcinoma. Otolaryngol Head Neck Surg 134:147- 152. TannerMM, TirkkonenM, Kallioniemi A, Holli K, Collins C, Kowbel D, GrayJW, Kallioniemi OP, Isola J (1995): Amplificationof chromosomalregion 20ql3 in invasive breastcancer:prognostic implications. CIin Cancer Res I : 1455-1461. TemamS, KawaguchiH, El-NaggarAK. JelinekJ, Tang H, Liu DD, Lang W, lssa JP, Lee JJ, Mao L (2007): Epidermalgrowth factor receptorcopy numberalterationscorrelatewith poor clinical outcome in patients with head and neck squamouscancer. J C h Oncol25:2164-2 170.

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TUMORS OF THE UPPER AERODIGESTIVE TRACT

Timpson P, Wilson AS, LehrbachGM, SutherlandRL, MusgroveEA, Daly RJ (2007): Aberrant expressionof cortactinin headandnecksquamouscell carcinomacells is associatedwithenhanced cell proliferationandresistanceto the epidermalgrowthfactorreceptorinhibitorgefitinib.Cancer Res 67:9304-93 14. ToidaM, Balms M, MoriT,IshimaruJI,IchiharaH, FujitsukaH,HyodoI, YokoyamaK,TatematsuN, AdanyR (2001): Analysisof geneticalterationsin salivaryglandtumorsby comparativegenomic hybridization.Cancer Genet Cytogenet 127:34-37. TononG, Modi S, Wu L, KuboA, CoxonAB, KomiyaT, O’Neil K, StoverK, El-NaggarA, GriffinJD, Kirsch IR. KayeFJ(2003): t( 11 ;19)(q21;p13) translocationin mucoepidermoidcarcinomacreates a novel fusion productthat disruptsa Notch signallingpathway.Nut Genet 33:208-213. Tsao SW, Liu Y,Wang X,Yuen PW, LeungSY, Yuen ST, Pan J. Nicholls JM,CheungAL, Wong YC (2003):The associationof E-cadherinexpressionandthe methylationstatusof theE-cadheringene in nasopharyngealcarcinomacells. Eur J Cancer 39:524-53 I . Uchida K, Oga A. OkafujiM, MiharaM,KawauchiS, FuruyaT,Chochi Y, Ueyama Y,Sasaki K (2006): Molecularcytogeneticanalysisof oralsquamouscell carcinomasby comparativegenomic hybridization,spectralkaryotyping,and fluorescencein situ hybridization.Cancer Genet Cytogenet 167:10%116. van derRiet P, NawrozH, HrubanRH,CorioR, TokinoK, Koch W, SidranskyD ( 1994):Frequentloss of chromosome9~21-22early in head and neck cancerprogression.Cancer Res 54: 1156-1 158. Van DykeDL, WorshamMJ, BenningerMS, KrauseCJ,BakerSR, Wolf GT,DrumhellerT, Tilley BC, CareyTE (1994): Recurrentcytogeneticabnormalitiesin squamouscell carcinomasof the head and neck region. Genes Chromosomes Cancer 9: 192-206. VanDevanter DR, George D, McNutt MA, Vogel A, LuthardtF (1991): Trisomy 8 in primary esthesioneuroblastoma. Cancer Genet Cytogenet 57: 133- 136. Virgilio L, Shuster M, Collin SM, Veronese ML, Ohta M, HuebnerK, Croce CM (1996): FHIT gene alterations in head and neck squamous cell carcinomas. Proc Natl Acad Sci USA 93:9770-9775. Voz ML,AstromAK, Kas K,MarkJ, StenmanG, Van de Ven WJ ( 1998): Therecurrenttranslocationt (5;8)(pI 3;q 12) in pleomorphicadenomasresultsin upregulationof PLAGl gene expressionunder controlof the LIFR promoter.Oncogene 16:1409-1416. WaghrayM, ParharRS, TaibahK, al-SedairyS (1992): Rearrangements of chromosomearm 3q in poorly differentiatednasopharyngealcarcinoma.Genes Chromosomes Cancer 4:326-330. qalch AK, ZitzelsbergerHF, Bink K, HutzlerP, BruchJ, BraselmannH, AubeleMM,MuellerJ, Stein H, Siewert JR, Hofler H, WernerM (2000a): Moleculargenetic changes in metastaticprimary Barrett’sadenocarcinomaand related lymph node metastases:comparisonwith nonmetastatic Barrett’sadenocarcinoma.Mod Puthol 132314-824. Walch AK, Zitzelsberger HF, Bruch J, Keller G, Angermeier D, Aubele MM, Mueller J, Stein H, BraselmannH. Siewert JR, Hofler H, WernerM (2000b): Chromosomalimbalances in Barrett’sadenocarcinomaand the metaplasia-dysplasia-carcinomasequence. Am J Pathol 156:555-566. WeberRG, ScheerM, Born lA, Joos S, CobbersJM, Hofele C, ReifcnbergerG, ZollerJE,LichterP ( 1998): Recurrentchromosomalimbalancesdetected in biopsy materialfrom oral premalignant and malignantlesions by combined tissue microdissection,universalDNA amplification,and comparativegenomic hybridization.Am J Pathol 153:295-303. WeberF, Xu Y, ZhangL, PatocsA, Shen L, PlatzerP, Eng C (2007): Microenvironmentalgenomic alterationsand clinicopathologicalbehaviorin head and neck squamouscell carcinoma.JAMA 297: 187-195. Whang-PengJ, Freter CE. Knutsen T, Nanfro JJ, Gazdar A (1987): Translocationt( 1 I ;22) in Cancer Genet Cytogenet 29: 155-157. esthesioneuroblastoma.

REFERENCES

413

Wolff E, Girod S, LiehrT, VorderwulbeckeU, Ries J, SteiningerH, GebhartE (1998):Oralsquamous cell carcinomasarecharacterizedby a ratheruniformpatternof genomic imbalancesdetectedby comparativegenomic hybridisation.Oral Oncol34:186-1 90. Wong N, Hui AB, Fan B, Lo KW, Pang E, b u n g SF, Huang DP, Johnson PJ (2003): Molecular cytogenetic characterizationof nasopharyngealcarcinomacell lines and xenograftsby comparative genomic hybridizationand spectral karyotyping. Cancer Genet Cytogenel 140 124-132. WorshamMJ, WolmanSR. CareyTE, ZarboRJ, BenningerMS, Van Dyke DL (1 999):Chromosomal aberrationsidentified in cultureof squamouscarcinomasare confirmed by fluorescence in situ hybridisation.Mol Pathol52:4246. WreesmannVB, Singh B (2005):Chromosomalaberrationsin squamouscell carcinomasof the upper aerodigestivetract:biologic insights and clinical opportunities.J Oral Puthol Med 34:449-459. WreesmannVB, Wang D, CoberdhanA, PrasadM, Ngai I, SchnaserEX,SacksFG,Singh B (2004): Genetic abnormalitiesassociated with nodal metastasis in head and neck cancer. Head Neck 26:10-1 5. Wu CL, Sloan P, Read A& Hams R, Thakker N (1994): Deletion mapping on the short arm of chromosome3 in squamouscell carcinomaof the oral cavity. Cuncer Res 54:6484-6488. Wu TT,Barnes L, Bakker A. Swalsky PA, Finkelstein SD (1996): K-ras-2and p53 genotyping of intestinal-typeadenocarcinomaof the nasal cavity and paranasalsinuses. ModPuthol9: 199-204. Wu TT, Watanabe T,Heitmiller R, Zahurak M, Forastiere AA, Hamilton SR (1998): Genetic alterationsin Barrett esophagus and adenocarcinomasof the esophagus and esophagogastric junction region. Am J Pathol 153:287-294. Yan W, Song L,Wei W, Li A. Liu J, FangY (2005):Chromosomalabnormalitiesassociatedwith neck nodal metastasis in nasopharyngealcarcinoma. Turn Biol 26:306-3 12. Yau WL, Lung HL, ZabarovskyER, LermanMI, Sham JS, ChuaDT, Tsao SW, StanbridgeEJ, Lung 3 tumorsuppressorgene BLU/ ML (2006):Functionalstudiesof the chromosome3 ~ 2 1 . candidate ZMYNDIO in nasopharyngealcarcinoma.In1 J Cancer I19:2821-2826. Yu Y,BarasAS, ShirasunaK, FriersonHFJr, MoskalukCA (2007):Concurrentloss of heterozygosity and copy number analysis in adenoid cystic carcinoma by SNP genotyping arrays. Lab Invest 87:430439.

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CHAPTER12

Tumors of the Lung PENNY NYMARK, EEVA KETTUNEN, and SAKARI KNUUTllA

Karyotypic informationis available on three main types of lung tumors: pulmonary hamartomas,bronchialcarcinoids,and the genuine lung cancers. Pulmonary humartomas arebenigntumorsthatoccurin 0.25% of the population.In the largeststudyto date(Kazmierczaket al., 1999), I9 I sampleswereexaminedconfirmingthat rearrangementsof 6 ~ 2 1 . 3(1 I%) and 12q14-15 (50%) are common in these tumors. Furthermore,14q24 was identifiedas the preferredsite of translocationfor both 6p2 1 and 12q14-15, being involved in 20% of the cases. The two genes HMGAI (6~21.3)and HMGAZ ( 12914.3) arethoughtto be involved in theserearrangements by translocationto a highlyexpressedregionat 14q;hence, overexpressionof eitherof thesegenes seems to be a major mechanism in tumor development (Kazmierczaket al., 1999). Other benign mesenchymaltumors,too, frequentlycarrythe same type of 12q aberrations(Chapter23; Schoenmakerset al., 1994). Also otheraberrations,includingrearrangements of 17p,have been associated with pulmonaryhamartomas(Johanssonet al., 1993b). Occupational exposures (excluding smoking) in men have been significantly related to an increased numberof chromosomalaberrationsin these tumors(Kayseret al., 2003). Bronchial carcinoids are neuroendocrinetumorsthatcan be classifiedas eitheratypical carcinoids(AC) or typical carcinoids(TC). AC are more aggressiveand generallydisplay more extensivegenomic aberrationscomparedto TC. Some recurrentcytogeneticaberrationshavebeen identified,suchas trisomy7 (Johanssonel al., 1993~) andloss at 1 Iq, which havebeen detectedin roughlyhalf of all cases, somewhatmorefrequentlyin AC thanin TC (Walchetal., 1998).A tumorsuppressorgene(TSG)at1 lq13.1, MEN1,hasbeenclaimedto be involved in the developmentof lung carcinoids,and this gene has also been foundto be affectedby mutations,loss of heterozygosity(LOH),andmicrosatelliteinstability(MSI)in such tumors(Ullmannet al., 1998; Walch et al., 1998). LOH studies have also identified losses of theRBI gene (20%)(Zhaoet al., 2000;Beasley et al., 2003) andelsewherein 13qas well as in IOq,3p. 9p21, and 17p (Walchet al., 1998). These aberrationsare also typicalof small-cell lung cancer (SCLC) (discussed below), anotherneuroendocrinetumor,where they occureven morefrequentlythantheydo in AC (Onukiet al., 1999).ThegeneRASSFIA at 3p21.3 has been found to be methylatedin 7 I % of AC and in 45% of TC, although

Cancer Cyrogenetics, Third Edition, edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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methylation and silencing of TSG are otherwise relatively rare events in carcinoids comparedto other lung cancers(Toyookaet al., 2001). The mostextensivelystudiedtumorsof thelungarethegenuinelung cancers,which cause the mostcancer-related deathsall overthe world.They areclassifiedintonon-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC is furtherdivided into adenocarcinoma (AdC), squamous cell carcinoma (SCC), and large cell lung cancer (LCLC),as well as other less common types such as adenosquamous carcinoma (AdC/ SCC) and sarcomatoid carcinoma (SC). Nearly all lung carcinomasexhibitboth multiple structuraland numericalcytogeneticabnormalities(Balsaraand Testa, 2002; Pananiand Roussos, 2006). The karyotypesof over400 lung carcinomascan be found in the Mitelman Databaseof ChromosomeAberrationsin Cancer(Mitelmanet al., 2008), andmicroarraydata on a few lungcancersamplescan be foundin the CanGEMdatabase(Scheininet al., 2008). The most frequent(70- 100%) large aberrationsdetected by chromosomalcomparative genomichybridization(CGH)(Fig. 12.1) in lung cancerare gains at 1q, 3q, 5p, and 8q and losses at3p, 5q, I3q, and 17p(Michellandet al., 1999; Girardet al., 2000, Struski et al., 2002). 3p21.3 has been one of the most extensively studiedsubbands,and severalpotentialTSG have been identified here, such as RASSFIA, which has also been frequently found methylatedin lung cancer irrespectiveof smoking status(Liu et al., 2007). LOH at 3p21 hasbeen associatedwith an earlyage of onsetof smoking(Hiraoet al., 2001). Loss of 3p21.3 in lungcancer,as well as down-regulationof genes locatedhere,has been linkedto asbestos exposure(Marsitet al., 2004;Nymarket al., 2006). The tumorsuppressorgene FHIT(3pl4) appearsto be down-regulatedin lung cancersof smokers(Pylkkiinenet al., 2002a).

20% 13 20%

20% 14 20%

20% 15 20%

FIGURE 12.1 Recurrent DNA copy number alterations in cancers of the lung and bronchi (www. progenetix.de/progenetix/LC34/). Losses are shown to the left, gains to the right.

TUMORS OF THE LUNG

417

Lungcarcinomasin patientswith no evidentexposureto carcinogenshave been shown to carryfeweraberrationsthanthose of patientswith known exposuressuch as tobaccosmoke (Sanchez-Cespedeset al., 1998;Grepmeieret al., 2005). Mutationsof the epidermalgrowth factor receptorgene (EGFR) in 7pl1 are specifically associatedwith cancers in neversmokers.Also TP53 mutationsand allelic loss of FHITseemto be morecommonin tumors of never-smokers(Sun et al., 2007). Almost 80%of all lung carcinomasbelong to the NSCLCcategory.In general,the most recurrentimbalancesin thesetumorsaregainsat I q, 3q, 5p,and89 as well as losses at 3p, 8p, 9p, 13q, and 17p (Balsaraand Testa, 2002; Hoglund et al., 2004; Tonon et al., 2005a). Inactivationof CDKN2A (9~21.3)by multiplemechanisms,includingdeletion(30-60%), occurs frequently in NSCLC, apparentlyexclusively in smokers (Merlo et al., 1995; Brambillaetal., 1999;Pananiand Roussos,2006; Wikmanand Kettunen,2006). Recently, a largestudyanalyzing37 I AdC by meansof single nucleotidepolymorphism(SNP)arrays found that 26 of the 39 autosomalchromosomearmswere involved in Iarge-scalecopy numbergains and losses, with the most frequentalterationbeing gain of 5p (60%).A totalof 31 recurrentaberrationswere identified,of which amplificationof 14q13.3 was the most frequent ( 12%). Additionally,the study identified a proto-oncogene (NKx2- I) in this subbandas well as LOH at 17pand 19p (Weiret al., 2007). Othercommonaberrationsin AdC are gains at 7p, 16p, 17q, and 20q and losses at 5q, 6q, 15q, 18q, and 19 (Petersen et al., 1997;Shibataet al., 2005; Choi et al.. 2006). Gainsat 16phave been identifiedas the most frequent aberrationsin AdC of never-smokers(Wong et al., 2003). High-level amplificationshave been identifiedat 12q34-I5 (CDK#), 7p12 (EGFR), 1 lq13 (CCNDI), and 17q2I (ERBB2) (Shibataet ai., 2005; Wikmanet al., 2005).Losses at 2q, 6, Sp, 9q, I3q, and 15q and focal amplificationsat chromosomes1 2 and 14 and 17p are morecommon in AdC thanin otherNSCLC (Sy et al., 2004; Gamiset al., 2006). but the amplitudeof these changes vanes from study to study.ParticularLOH patternshave been identifiedin AdC, suggesting that synergisticinteractionsbetween losses of putativetumor suppressorsin theseregionsplay a rolein tumorigenesis.Theregionsthusdetectedwere I p and 1 q together with 3p, 20p together with 3p, 3q together with 15q, and 6p together with 5p (Girard et al., 2000). Amplificationand overexpressionof CKSIB at Iq21 have been detected in regionof Iq has been associated AdC (Jianget al., 2004), and gain of the near-centromeric with metastkisformation(Goeze et al., 2002). Loss of 13q14.1 and gain of 8q24.2 have been associatedwith disease-freesurvival,andgainof 19q13.1as well as loss of 22q12.2has been linked with currentor formersmokinghistoryin AdC (Shibataet al., 2005). In SCC,also called epidermoidcarcinoma,gain of 3q is a commonchange.The minimal overlappingregion in 3q variesfromstudy to study;however,distinctdifferencesbetween SCCandAdC have been noted,with the gainsmoreoftenmappingto 3q23-26 in the former and to 3q22 in the latter(Tonon et al., 2005b; Garniset al., 2006). Other studies have reportedthe minimalcommongainedregion to 3q25-29 in SCC, and so this issue remains unresolved(Tai et al., 2004). Overexpressionof the gene TP63 (3q28) and mutationsin PIK3CA (3q26) have been foundin SCC(Tononet al., 2005a; Kawanoet al., 2006). Apart from 3q, SCC generallydisplay the same gain/loss patternsthat are seen in AdC (Garnis et al., 2006), althoughgainsat 2p and9q as well as losses at 8p and I 3q havebeenreportedto be morefrequentin SCC(Sy et al., 2004; Lo et al., 2008).In addition,SKP2 (5pl3) has been found to be more frequentlyamplified in SCC than in AdC (Jiang et al., 2004) and overexpressionof this gene has been related to metastasisand poorerprognosis (Yokoi et al.. 2004; Takanami,2005). Gainsat 3q21-25 and 8qll-25 as well as losses at 3p 12-14, 4~15-16, 8p22-23, IOq, and 21q have been associatedwith a metastaticphenotype.

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LCLC has the highest mean chromosomenumberand DNA contentof all lung cancer types(Petersen,2003). The karyotypesin non-newoendocrinetypesof LCLCexhibitsome similaritieswith AdC and SCC, such as gains of Iq and 3q. Also otherrecurrentchanges, includinggains of 1q21-22 and8q andlosses of 3p12-14,4p, 8p22-23, and 21q, havebeen reported(Bjorkqvistet al., 1998). Large-cellneuroendocrinecarcinoma(LCNEC)exhibits similarities with SCLC (discussed below) (Ullmann et al., 1998, 2001). In AdC/SCC, alterationsin each histologic componentare characteristicfor AdC and SCC. Sarcomatoid carcinomasare generallycharacterizedby gains ratherthanlosses (Torenbeeket al., 1999; Blaukovitschet al., 2006). The mostfrequentgainsarefoundon chromosome1 followed by 8q and chromosome3. The pleomorphicand spindle cell tumortypes reveal gains from severalchromosomesandchromosomearms,including8q, 7,5,3q, 1,19, and 5p, whereas losses of 13p and 15q characterizethe giant-cell subtype. Carcinosarcomascan be differentiatedfrom other subtypes of SC by their propensity for gains at 2q and 14q. Gainson chromosome7 and 12pseparateSC from AdC, whereasgainson lq, 7, and 8 seem to differentiateSC from SCC (Sy et al., 2004: Blaukovitschet al., 2006). Finally,an oncogenic fusiongene, EMU-ALK, was recentlyidentifiedin 5 of 75 studied NSCLC,primarilyas a resultof a paracentricinversionin the shortarm of chromosome2, inv(2)(p21p23) (Soda et al., 2007). In addition, a t(15;19)(ql l;p13) interruptingthe NOTCH3 gene in 1 9 ~ 1 3was detected in a lung tumorof a nonsmokingyoung woman, and overexpressionof NOTCH3 has been significantlyassociatedwith abnormalitiesin chromosome 19 in seven other lung cancer cell lines (Dang et al., 2000). Loss and downregulationof genes at 1 9 ~ 1 3have been linked to asbestosexposurein lung cancer (Wikmanet al., 2007; Ruosaariet al., 2008). SCLC account for one-fifth of all lung cancers and are, together with LCNFC and carcinoids,consideredto be neuroendocrinetumors. The first recurrentalterationto be identifiedin almost 100%of SCLCwas loss of 3p, which was subsequentlyalso frequently detectedin NSCLC(Whang-Penget al., 1982). Morerecently,SCLChave been shownto be characterizedalso by losses at 4q, 5q, and 1Oq (Schwendelet al., 1997;Ashmanet al., 2002; Hoglundet al., 2004). Otherrecurrentaberrationsin SCLC includegains at 3q, 5p, 6p, 8q, 17q, 19, and 20q as well as losses at 13q and 17p (Balsaraand Testa, 2002). Thereis a correlationbetween LOH at 4q and 5q, 3p and 13q, and 13q and 17p, indicatingthat synergismmay exist amongTSG in these regions;a similarphenomenonwas notedalso for AdC (Girardet al., 2000). In addition, SCLC have been shown to harborunbalanced translocations,mainlyinvolving3q 13.2andchromosome5 (Ashmanet al., 2002). SCLC,as well as LCNEC,have been shownto exhibitloss of RBI (1 3q 14.2) expressionin up to 90% of thecases, mainlyattributableto deletions,whereasonly 25%of NSCLC show loss of this gene (Wikmanand Kettunen,2006).

ARE THE EARLY CHROMOSOMAL ALTERATIONS IN LUNG CANCER USEFUL AS TARGETS FOR DIAGNOSTIC TESTS? It is becomingmoreandmore importantfor our understandingof tumorigenesisto unravel the orderin which karyotypicchanges occur. Hoglund.etal. (2004) examinedthe copy numberchanges in 432 lung carcinomasand concludedthat they displayedcharacteristic aberrationpatternsleadingto specific imbalanceprofiles thatwere largely similaramong the differentsubtypes.They furtherproposedthat lung cancerdevelopsvia eitherof three mainpathways,in which 7,3p-, or 12 is theinitialchromosomalchange,respectively.

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The 3p- pathwayis dominatedby losses whereasthe 12 pathwayis dominatedby gains. The + 7 pathway also often had gain of an additionalchromosome20, but otherwise showed only few changes.Besides defininga separatepathwayof its own, however,gain of chromosome7 was sometimesimplicatedas a laterchangein the 3p- pathwayillustrating that these pathogeneticmechanismswere not altogetherseparate(Hoglundet al., 2004). Interestingly,trisomy 7 has also been identifiedin nonmalignantlung epithelialcells from lung cancerpatients(Varella-Garciaet al., 2007), in histologicallynormallung epithelium from smokers (Slebos et al., 2005). as well as in a numberof nonneoplasticconditions (Johanssonet al., 1993a). Six distinct regions of amplificationhave been identified on chromosome7 in NSCLC,two of which (7~22.1-22.3 and 7pl I .2-15.3) were identifiedin > 80%of the 28 cases studiedby Garniset al. (2006). Mutationsandoverexpressionof the gene EGFRat 7p 12 have been found to correlatewith amplification.Overexpressionhas been foundin 70%of SCCand40%AdC of the lung (Franklinet al., 2002). Theremay well be otherearly changes, such as LOH at 8p, 9p, I Iq, and 13q, since these are regions that harborgatekeeperTSG(Panet al., 2005). Furthermore, LOHfromthe TSCI regionat 9q and the TSC2 regionat I6phasbeen relatedto atypicaladenomatoushyperplasiaprecedingAdC (Takamochiet al., 2001). Lung cancerpatientshave higheramountsof free circulatingDNA in both sputumand serum(Xue et al., 2006). Many studieshave attemptedto identify specific aberrationsthat could be detected in sputumor serum of lung cancerpatientsor in high-riskgroups;for example,LOH at 3p has been identifiedin serum DNA from NSCLC patients(SanchezCespedeset al., 1998).Deletionof the genes HYAL2 ( 3 ~ 2 1and ) FHIT(3p14)in sputumhas been claimed to represent valid diagnostic markers for early-stage lung cancer (Li et al., 2007). Also detection of LOH at 9p, 12p, and 13q in sputum and plasma DNA collectedfrom lungcancerpatientshas been proposedto be reliablediseasemarkers(Wang et al., 2006), and severalotherearly changes, such as deletions at 2q and 12p, have been identifiedin bronchialwashings, normalbronchialepithelium,and sputumsamplesfrom lung cancer patients(Grepmeieret al., 2005; Varella-Garciaet a]., 2007). However, the consistencyandreliabilityof suchtests in clinical settingsstill need to be evaluated(Slebos et al., 2005). Finally, a commercialfluorescencein situ hybridization(FISH)test, LaVysion (Vysis Inc/Abbott),hasbeendeveloped.Thistestdeterminesthecopy numberof thecentromereof (EGFR), and 8q24 (MYC); the latter two oncogenes are chromosome 6, 5 ~ 1 5 7p12 , frequentlyamplified in lung cancer. The probe set has, when applied to sputumcells, been shown to be able to identify lung cancer patients, but it could not differentiate individualsat high risk of lung cancer from the normal control population(Kettunen et al., 2006). Otherloci thathavebeen FISH-testedfortheirusefulnessin earlydiagnosisare 10q22 and 3 ~ 2 2 . 1(Barkanet al., 2005).

THERAPEUTIC IMPORTANCE OF ACQUIRED GENOMIC ALTERATIONS IN LUNG CANCER

.

Despite many years of clinical research,only a few recurrentgenomic aberrationsin lung cancer have been targeted by generally approved therapeutics.One of these is the amplificationand overexpressionof EGFR. Two EGFR tyrosine kinase inhibitors(TKT) have been developed and extensivelystudiedas lung cancerdrugs,gefitiniband erlotinib. Studieshave demonstratedthatfemale patients,Japanesepatients,patientswith AdC, and

420

TUMORS OF THE LUNG

nonsmokerswith lungcancerrespondfavorablywhen treatedwith theseTKI.Furthermore, some studies (reviewed in Besse et al., 2007) but not all (Pugh et al., 2007) indicatethat mutationsin the EGFR gene may predictthe responseto gefitinib.The superiorityof these therapeuticapproachescomparedto chemotherapyalonehas not yet been proven,however (Besse et al., 2007). Anotherapprovedtreatmentfor advancedNSCLC is bevacizumab, which targets angiogenesis by interferingwith the productof the VEGF gene at 6p21. Severalothertrialsareongoing,targetingtheERBBZ gene in 17q21andtheproteinkinaseC (PKC) pathway (e.g., PRKCI at 3q26) (Besse et al., 2007; Fields and Regala, 2007). In addition,the possibilityof inhibitionof cyclin-dependentkinases (e.g., CDK4 at 12q14) is being evaluated.Unfortunately,similarstudieson SCLChave rarelybeen conducted,even thoughthis disease is often moreaggressiveand is associatedwith a poorerprognosisthan NSCLC. At the present time, therefore, although more than 500 molecular targeted therapies for lung cancer are being developed, their benefits have been difficult to demonstrateand many trialshave failed (Besse et al., 2007).

PLEURA Primarypleuraltumorsareextremelyrare(reviewedin Granvilleet al., 2005). Someof them arenot typicalof this tissue and organ;for example,the specific translocationt(X;18)(pl1; q l I ) causing a SYT-SSX fusion gene was detected in a synovial sarcomaof the pleura (Begueretet al., 2005). The principaltumortype of the pleurais malignantmesothelioma. Most of these tumors are believed to develop as a consequence of previous asbestos exposure,but with a very long latency period. Close to 100 mesotheliomaswith complexchromosomalaberrationshavebeen reported (Tiainenet al., 1988; Hagemeijeret al., 1990; Ribottaet al., 1998; Mitelmanet al., 2008). 7, - 1, - 3, -4,6q-, -9, 1 1, - 14, and 3p-. The most commonaberrationsare -22, Losses of chromosomes1 and 4 and a breakpointat lpll-22 have been relatedto a high asbestos fibercontent in the tumors(Tiainenet al., 1989). Similarto the situationin lung tumors,a more detailed view of the acquiredgenomic imbalancesof mesotheliomashas emergedthroughchromosomaland array CGH studies (Knuutila,2004). The gains in mesotheliomaprimarilyinvolve chromosomearms5p, 7p, 7q, 8q, and 17q, whereas losses affect nearly all chromosome's.The most common aberration,describedin more than 80%,includingearly-stageepithelial-typetumors(see below), is a homozygousdeletionof 9p21.3 affectingthe CDKN2A and occasionallyalso adjacentgenes (Simonet al., 2005; Pei et al., 2006;Taniguchiet al., 2007). Loss of CDKN2A is associatedwith a bleak prognosis in mesothelioma(Lopez-Rioset al., 2006). Another frequentlyalteredregion is at 22q and includes the neurofibromatosis2 gene (NF2). The NF2 region, together with 9p, 3p (FHZZ'), 14q, and 6q, has all shown frequentLOH (F'ylkkanenet al., 2002b). Inactivationof the NF2 gene producthas been associated with invasivenessin mesotheliomacells (Poulikakoset al., 2006). Asbestos fibers have been shown to activateEGFR expression.However, those same EGFR mutationsth'atin lung adenocarcinomaseem to confersensitivityto EGFR targeted therapy, are absent in mesothelioma. This means that patients with mesotheliomaare unresponsiveto gefitinib(Govindanet al., 2005; Corteseet al., 2006). The histological mesotheliomasubtypes,namely epithelial,sarcomatoid,and biphasic tumors,show partlydistinctaberrationpatterns.Epithelialmesotheliomahai been associated with gain of 7q and losses at 3pl4-21 and I7pl2-pter,whereassarcomatoidmesothelioma

+

+

421

PLEURA

displaysgains at5p, 8q, and 17q andlosses at 7q and 15q(Krismannet al., 2002). Theoverall gaidloss patternof mesotheliomasmay assist the differentiationof these tumorsfrompleural sarcomasand lungcarcinomas.GenomicCGHprofilinghascommonlydetectedlosses at 4p, 4q, 6q, 14q, and 9p and gains at 15q in mesothelioma,whereasgains at 8q, I q, 7p, and 6p dominatein lung carcinomas(Fig. 12.2) (Bjorkqvistet al., 1998; Knuuttilaet al., 2006). The sensitivityof CGHanalysisin differentiatingmesotheliomafromlung carcinomaswas 8 1%, with a specificityof 77%(Bjorkqvistet al., 1998). Also the expressionlevels of certaingenes such as calretinin, TACSTDI, and claudin-7 may help differentiatemesotheliomafrom adenocarcinomaof the lung (Gordonet al., 2002).

MM

LC

I I

I2

1

6

6

10

10

2

3

7

3

a

8

9

9

11

Ill& ‘If/ 13

13

El

!!I

21

21

14

118 22

..

14

15

15

16

16

17

II

17

1 fg, I I1

18

18

22

FIGURE 12.2 DNA copy number profiling in 27 malignant pleural mesotheliomas and 26 lung carcinomas.Lossesareshownto the left andgainsto the right.Dotted lines aregains (2 1.3 and < 1.5) and bold lines are “amplifications” ( > 1.5) (adapted from Fig. 1 in Bjorkqvistet al., 1998). MM, malignant mesotheliomaand LC, lung carcinoma.

422

TUMORS OF THE LUNG

Molecularkaryotypingof mesotheliomaby arrayCGHhasrevealedsomenovelregionsof genomic losses, gains, and high-level amplification.Novel gains at 9p13.3, 7~22.2-22.3, 12q13.3, and 17q21.32-qter were detected in primary rnesotheliomasby Lindholm et al. (2007). Amplificationat 1 p32 correlatedwith overexpressionof the JUN oncogene in vivo (Taniguchiet al., 2007). Ina mesotheliomacell line,some aberrations,includinggains at 2p21,2p12-16.2, and 12q13.I 1-qter,occurredonly in the early passages,whereasother gains, for example at lp34 and 3~25.1,were exclusively found in late passages and were believedto reflectclonalevolutionin vitro(Zanazziet al., 2007). The aberrationsfoundboth at earlyand late passagesof this mesotheliomacell line differedfromthose foundin earlystage epithelioidmesotheliomas(Simon et al.. 2005). When evaluatingsuch studies,one should bear in mind both the drawbacksassociatedwith high-throughputarraystudies in termsof variabilityof the resultingdataandalso thattheinformationvalueof cell line studies with regardto thein vivo situationmay be limited.Althoughsome investigatorsmaintainthat expressionprofilingof certaingene sets in mesotheliomamay be clinicallyuseful, thisclaim has not yet been criticallyevaluated(Gordonet al., 2003,2005; Lopez-Rioset al., 2006).

SUMMARY The benign pulmonaryhamartomasoften show rearrangementsinvolving 6p21.3 and 12q14-15, especially in recombinationwith 14q24. HMGAl at 6p21.3 and HMGAZ at 12q14.3 are believed to be the genes targetedby these rearrangements. Chromosomalaberrationsin malignanttumorsof the lung and pleuraarecomplex and involvealmostall chromosomes.In bronchialcarcinoids,trisomy7 anddeletionsat 1I q are frequent.In all types of the so-calledgenuinelung carcinomas,the most frequentgainsare foundat 1q, 3q,5p,and8q withlosses at3p,5q, 1 3q,and 17p.Theseaberrations arelargelythe same in bothsmallcell and non-smallcell lungcancer.In addition,high-levelamplifications have been identified at 12q14-15 (CDK4), 7p12 (EGFR), 1lq13 (CCNDI), and 17q21 (ERBB2).Adenocarcinomasandsquamouscell carcinomasfollow muchthe samepatternof aberrations. However,gainsdistallyin 3q arecharacteristicforSCCandgainsat I6paremore frequentlyseen in AdC.Loss of 3p is seen in almost 100%of SCLC,butthesetumorsarealso characterizedby specific losses at 4q, 5q, and 1%. Translocationshavebeen very difficultto identifyin lungcancersduetothecomplexityof thekaryotypes.Nevertheless,somebalanced as well as unbalancedtranslocationshave been recognized,such as those involving 8q in NSCLCand 3q andchromosome5 in SCLC.Furthermore, the fusion gene E M U - A M , the resultof a smallinversionin chromosomearm 2p, was recentlydiscoveredin NSCLC.Loss andgain of tumorsuppressorsand oncogeneshave been well documentedin lung cancers. BothSCLCandlargecellneuroendocrinecarcinomascanshowlossofRBI(13q14.2)inupto 90%of the tumors,but silencingof CDKN2A is relativelyrarein SCLC.In contrast,patients with NSCLCand a smokinghistoryfrequentlyshow silencingof CDKN2A in theirtumor cells, usually becauseit is deleted. Otherexposure-relatedaberrationsare loss and down3 asbestosexposureis an etiologic agent.LOHat regulationof genes at 3p21 and 1 9 ~ 1when 3p21 has also been linked to early-onsetsmoking. Pleural mesotheliomasalso have extremely complex karyotypes.The most frequent aberrationshave been -22, +7, - I , -3, -4, 6q-, -9, + 1 I , and -14. Losses of chromosomes 1 and 4 and a breakpointat lpli-22 have been associated with a high asbestosfibercontent.Deletion at 9p2i (CDKN2) is recurrentand an unfavorablesign. At present,no consistentchromosomaltranslocationshave been describedin mesothelioma.

REFERENCES

423

REFERENCES Ashman JN, BrighamJ, Cowen ME, Bahia H, GreenmanJ, Lind M, Cawkwell L (2002): Chromosomal alterationsin small cell lung cancerrevealed by multicolourfluorescencein situ hybridisation. Int J Cancer 102:230-236. Balsara BR, Testa JR (2002): Chromosomal imbalances in human lung cancer. Oncogene 2 I :6877-6883. BarkanGA, CarawayNP, Jiang F, Zaidi TM, FemandezR, VaporcyinA, Morice R, Zhou X, Bekele BN, Katz RL (2005): Comparisonof molecular abnormalitiesin bronchialbrushingsand tumor touch preparations.Cancer L05:35-43. Beasley MB, LantuejoulS, AbbondanzoS, ChuWS, Hasleton PS. TravisWD, BrambillaE (2003): The P16/cyclin DI/Rb pathway in neuroendocrine tumors of the lung. Hum Pathol 34: 136-142. Begueret H, Galateau-SalleF, Guillou L, Chetaille B, BrambillaE, VignaudJM,TerrierP. Groussard 0, CoindreJM (2005): Pnmaryintrathoracicsynovial sarcoma:a clinicopathologic study of 40 t(X; 18)-positivecasesfromtheFrenchSarcomaGroupandthe MesopathGroup.Am JSurg Pathol 29~339-346. Besse B, RopertS, SoriaJC(2007): Targetedtherapiesin lung cancer.Ann Oncol I8 Suppl9: 135-142. BjorkqvistAM, TammilehtoL, Nordling S, NurminenM, Anttila S, MattsonK, KnuutilaS (1998): Comparisonof DNA copy number changes in malignant mesothelioma, adenocarcinomaand large-cell anaplasticcarcinomaof the lung. Br J Cancer 77:260-269. Blaukovitsch M,Halbwedl 1, KothmaierH, Gogg-KammererM,Popper HH (2006): Sarcomatoid carcinomas of the lung-are these histogenetically heterogeneous tumors? Virchows Arch 449:45546 I. BrambillaE, Gazzeri S, Moro D, LantuejoulS, Veyrenc S. Brambilla C (1999): Alterations of Rb pathway(Rb-p l6INK4-cyclin D 1 ) in preinvasivebronchial lesions. Clin Cancer Res 5:243-250. Choi JS, Zheng LT, Ha E, Lim YJ, Kim YH, Wang YP, Lim Y (2006): Comparativegenomic hybridizationarrayanalysis and real-time PCR reveals genomic copy numberalterationfor lung adenocarcinomas.Lung I84:355-362. CorteseJF, Gowda AL, Wali A, Eliason JF, Pass HI, Everson RB (2006): Common EGFR mutations confemng sensitivity to gefitinib in lung adenocarcinomaare not prevalentin human malignant mesothelioma. lqt J Cancer 11 8521-522. Dang TP, GazdarAF, Virmani AK, Sepetavec T, Hande KR, Minna JD. Roberts JR, Carbone DP (2000): Chromosome 19 translocation,overexpressionof Notch3, and humanlung cancer.J Natl Cancer Inst 92: 1355- 1357. Fields AP, Regala RP (2007): Protein kinase C iota: human oncogene, prognostic marker and therapeutictarget. Pharmacol Res 5 5 4 8 7 4 9 7 . FranklinWA, Veve R, Hirsch FR, HelfrichBA, Bunn PA Jr(2002): Epidermalgrowthfactorreceptor family in lung cancer and premalignancy.Semin Oncol29:3- 14. GamisC, Lockwood WW, Vucic E, Ge Y, GirardL, MinnaJD, GazdarAF, LamS, MacAulayC, Lam W L (2006): High resolution analysis of non-small cell lung cancer cell lines by whole genome tiling path arrayCGH. Int J Cancer 1 18: 1556- 1564. GirardL, Zochbauer-MullerS, VirmaniAK, GazdarAF, MinnaJD (2000): Genome-wideallelotyping of lung canceridentifiesnew regions oiallelic loss, differences between small cell lung cancerand non-small cell lung cancer, and loci clustering. Cancer Res 60:4894-4906. Goeze A, Schluns K, Wdlf G, ThaslerZ, PetersenS, Petersen I (2002): Chromosomalimbalancesof primaryand metastatic lung adenocarcinomas.J Pathol 196s-16. Gordon GJ, Jensen RV, Hsiao LL, Gullans SR, Blumenstock JE, Ramaswamy S, Richards WG, SugarbakerDJ, Bueno R (2002): Translationof microarraydata into clinically relevant cancer

424

TUMORS OF THE LUNG

diagnostic tests using gene expression ratios in lung cancer and mesothelioma. Cancer Res 62:4963-4967. Gordon GJ, Jensen RV, Hsiao LL, Gullans SR, Blumenstock JE, Richards WG, Jaklitsch MT. SugarbakerDJ, Bueno R (2003): Using gene expressionratiosto predictoutcomeamongpatients with mesothelioma.J Nut1 Cancer inst 95:598-605. GordonGJ,RockwellGN, GodfreyPA, JensenRV, GlickmanJN, Yeap BY, RichardsWG, Sugarbaker DJ. Bueno R (2005): Validation of genomics-based prognostic tests in malignant pleural mesothelioma.Clin Cancer Res 11:440W14. GovindanR. KratzkeRA, HerndonJE,NiehansGA, Vollmer R, WatsonD, GreenMR, KindlerHL (2005): Gefitinibin patientswith malignantmesothelioma:a phase I1 study by the Cancerand LeukemiaGroupB. Clin Cancer Res 11:2300-2304. GranvilleL, Laga AC, Allen TC, Dishop M, Roggli VL, ChurgA. ZanderDS, Cagle PT (2005): Review and updateof uncommonprimarypleuraltumors:a practicalapproachto diagnosis.Arch Pathol Lab Med 129: 1428-1443. GrepmeierU, DietmaierW, MerkJ, Wild PJ, ObermannEC, PfeiferM, HofstaedterF, HartmannA, WoenckhausM (2005): Deletions at chromosome2q and 12p are early and frequentmolecular alterationsin bronchialepitheliumand NSCLC of long-termsmokers.Int J Oncol27:481-488. HagemeijerA, Versnel MA, Van DrunenE, MoretM, Bouts MJ, van der KwastTH, HoogstedenHC ( 1990): Cytogeneticanalysisof malignantmesothelioma.Cancer Genet Cytogenet 47: 1-28. HiraoT,Nelson HH, Ashok TD, Wain JC, MarkEJ, ChristianiDC, WienckeJK, Kelsey KT (2001): Tobaccosmoke-inducedDNA damageandan earlyage of smokinginitiationinducechromosome loss at 3p21 in lung cancer. Cancer Res 61:612-615. Hoglund M, Gisselsson D. Hansen GB, Mitelman F (2004): Statisticaldissection of cytogenetic patternsin lungcancerrevealsmultiplemodesof karyotypicevolutionindependentof histological classification.Cancer Genet Cytogenet 154:99-109. JiangF, Yin Z, CarawayNP, Li R, KatzRL (2004):Genomicprofilesin stageI primarynon small cell lung cancerusing comparativegenomic hybridizationanalysisof cDNA micromays. Neoplasia 6:623-635. JohanssonB, Heim S, MandahlN, MertensF, MitelmanF (1993a):Trisomy7 in nonneoplasticcells. Genes Chromosomes Cancer 6: 199-205. JohanssonM, DietrichC, MandahlN, HambraeusG,JohanssonL, ClausenPP, MitelmanF, Heim S (1993b): Recombinationsof chromosomal bands 6p21 and 14q24 characterisepulmonary hamartomas.Br J Cancer 67:1236-1241. JohanssonM, Heim S, MandahlN, HambraeusG, JohanssonL, MitelmanF (1 993c): Cytogenetic analysisof six bronchialcarcinoids.Cancer Genet Cytogenet 66:33-38. Kawano0,SasakiH, EndoK, SuzukiE, HanedaH, Yukiue H, KobayashiY,Yano M, FujiiY (2006): PIK3CAmutationstatusin Japaneselung cancerpatients.Lung Cancer 54:209-215. KayserK, DunnwaldD, KazmierczakB, BullerdiekJ, KaltnerH, Zick Y, AndreS,GabiusHJ (2003): Chromosomalaberrations,profiles of expression of growth-relatedmarkersincludinggalectins and environmentalhazardsin relation to the incidence of chondroidpulmonaryhamartomas. Pathol Res Pract I99:589-598. KazmierczakB, Meyer-BolteK.TranKH,WockelW,Breightman1,RosigkeitJ,BartnitzkeS, Bullerdiek J(1999):AhighfrequencyoftumorswithremangementsofgenesoftheHMGI(Y)familyinaseriesof 19I pulmonarychondroidhamartomas.Genes Chromosomes Cancer 26: 125-1 33. KettunenE, SalmenkiviK, Vuopala K, ToljamoT, Kuosma E, Norppa H, KnuutilaS, Kaleva S, HuuskonenMS, AnttilaS (2006): Copy numbergainson 5 ~ 1 5 . 6 ~ I -q1 1 1.7~12,and 8q24 arerare in sputumcells of individualsat high risk of lung cancer.Lung Cancer 54:169-1 76. KnuutilaS, (2004): Amplicons:respiratorytract tumors.Atlas Genet Cytogenet Oncol Haematol http://www.infobiogen.fr/services/chromcancerl~pl~esp.ht~.

REFERENCES

425

KnuuttilaA, Jee KJ, Taskinen E, Wolff H, KnuutilaS, Anttila S (2006): Spindle cell tumoursof the pleura: a clinical, histological and comparativegenomic hybridizationanalysis of 14 cases. VirchowsArch 448:135-141. KrismannM, MullerKM,JaworskaM, JohnenG (2002): Molecularcytogeneticdifferences between histological subtypes of malignant mesotheliomas: DNA cytometry and comparativegenomic hybridizationof 90 cases. J Pathol 197:363-37 I . Li R. Todd NW, Qiu Q, Fan T, Zhao RY, RodgersWH, Fang HE%, Katz RL, Stass SA, Jiang F (2007): Geneticdeletionsin sputumas diagnosticmarkersforearlydetectionof stage I non-smallcell lung cancer. Cfin Cancer Res 13:482-487. LindholmPM, SalmenkiviK, VauhkonenH, Nicholson AG. AnttilaS, KinnulaVL, KnuutilaS (2007): Gene copy numberanalysis in malignantpleuralmesothelioma using oligonucleotidearrayCGH. Cytogenet Genome Res 119%-52. Liu Y, Gao W, Siegfried JM, Weissfeld JL, LuketichJD, Keohavong P (2007): Promotermethylation of RASSFlA andDAPK and mutationsof K-ras,p53, and EGFRin lung tumorsfrom smokersand never-smokers.BMC Cancer 7:74. Lo KC, Stein LC, PanzarellaJA, Cowell JK, HawthornL (2008): Identificationof genes involved in squamous cell carcinoma of the lung using synchronized data from DNA copy number and transcriptexpression profiling analysis. Lung Cancer 59:3 15-333. Lopez-Rios F, Chuai S, Flores R, Shimizu S, Ohno T, WakaharaK, Illei PB, Hussain S, Krug L, Zakowski MF, and others (2006): Global gene expression profiling of pleural mesotheliomas: overexpression of aurorakinases and P16/CDKN2A deletion as prognostic factors and critical evaluation of microarray-basedprognostic prediction.Cancer Res 66:297&2979. MarsitCJ, HasegawaM, HiraoT, Kim DH, Aldape K, HindsPW, WienckeJK,Nelson HH, Kelsey KT (2004): Loss of heterozygosity of chromosome3p2 1 is associated with mutantTP53 and better patient survival in non-small-cell lung cancer. Cancer Res 64:8702-8707. Merlo A, HermanJG, Mao L, Lee DJ, GabrielsonE, BurgerPC, Baylin SB. SidranskyD (1995): 5’ CpG island methylationis associated with transcriptionalsilencing of the tumoursuppressorp 16/ CDKNuMTSI in human cancers. Nut Med 1:686-692. MichellandS, Gazzeri S, BrambillaE, Robert-NicoudM (1999):Comparisonof chromosomalimbalances in neuroendocrineand non-small-celllung carcinomas.Cancer Genet Cytogenel 1 14:22-30. MitelmanF, JohanssonB, MertensF, editors.(2008): MitelmanDatabaseof ChromosomeAberrations in Cancerhttp://cgap.nci.nih.gov/Chromosomes/Mitelman. NymarkP, WikmanH, RuosaariS, HollmenJ,VanhalaE. KarjalainenA, AnttilaS , KnuutilaS (2006); Identificationof specific gene copy numberchanges in asbestos-relatedlung cancer. Cancer Res 665737-5743. Onuki N, Wistuba [I, Travis WD, Virmani AK, Yashima K, Brambilla E, Hasleton P, Gazdar AF (1999): Genetic changes in the spectrumof neuroendocrinelung tumors. Cancer 85:600-607. Pan H, Califano J, Ponte JF, Russo AL, Cheng KH, Thiagalingam A, Nemani P, Sidransky D, ThiagalingamS (2005): Loss of heterozygosity patternsprovide fingerprintsfor genetic heterogeneity in multistep cancer progression of tobacco smoke-induced non-small cell lung cancer. Cancer Res 65: 1 664- 1669. PananiAD, Roussos C (2006):Cytogeneticandmolecularaspectsof lung cancer.Cancer Lett 239:l-9. Pei J, KrugerWD, Testa JR (2006):High-resolutionanalysis of 9p loss in humancancercells using single nucleotide polymorphism-basedmapping arrays.Cancer Genet Cytogenet 170:65-68. Petersen I (2003): Comparativegenomic hybridizationof human lung cancer. MethodsMol Med 75:209-237. PetersenI, BujardM, PetersenS, Wolf G, Goeze A, Schwendel A, LangreckH, Gellert K, Reichel M, Just K,du ManoirS, CremerT, Dietel M,Ried T (1997): Patternsof chromosomalimbalancesin adenocarcinomaand squamouscell carcinomaof the lung. Cuncer Res 57:233 1-2335.

426

TUMORS OF THE LUNG

PoulikakosPI, Xiao GH,GallagherR, JablonskiS, JhanwarSC. TestaJR (2006): Re-expressionof the tumorsuppressorNF2merlininhibitsinvasivenessin mesotheliomacells andnegativelyregulates FAK. Oncogene 255960-5968. Pugh TJ,Bebb G, BarclayL, SutcliffeM, Fee J, Salski C, O’ConnorR, Ho C, MurrayN, Melosky B, EnglishJ, VielkindJ, HorsmanD, LaskinJJ,Marra MA (2007): Correlationsof EGFR mutations and increasesin EGFRand HER2copy numberto gefitinibresponse in a retrospectiveanalysisof lung cancerpatients. BMC Cancer 7: 128. Pylkkhen L, Wolff H. StjernvallT, TuominenP, Sioris T, KarjalainenA, Anttila S, HusgafvelPursiainenK (2002a): Reduced Fhit protein expression and loss of heterozygosity at FHIT gene in tumours from smoking and asbestos-exposed lung cancer patients. Int J Oncol 20~285-290. PylkkinenL, Sainio M, OllikainenT, MattsonK, NordlingS, Carpen0, LinnainmaaK, HusgafvelPursiainenK (2002b): ConcurrentLOH at multipleloci in humanmalignantmesotheliomawith preferentialloss of NF? gene region. Oncol Rep 9:955-959. RibottaM, Roseo F, Salvio M, CastagnetoB, CarboneM,ProcopioA, GiordanoA, MuttiL (1998): Recurrentchromosome6 abnormalitiesin malignantmesothelioma.Monaldi Arch Chest Dis 53~228-235. RuosaariST, NymarkPE, Aavikko MM, KettunenE, KnuutilaS, HollmCnJ, NorppaH, Anttila SL (2008):Aberrationsof chromosome19 in asbestos-associatedlungcancerandin asbestos-induced micronucleiof bronchialepithelialcells in vitro. Carcinogenesis 29:9 13-917 Sanchez-CespedesM, Monzo M, Rose11 R, PifarreA, Calvo R, Lopez-CabrerizoMP, Astudillo J (1998): Detection of chromosome3p alterationsin serum DNA of non-small-cell lung cancer patients.Ann Oncol9:113-1 16. Scheinin1, MyllykangasS, Borze I, BohlingT, KnuutilaS, SaharinenJ (2008): CanGEM:mininggene copy numberchangesin cancer. Nucleic Acids Res 36(Databaseissue): D830-835. SchoenmakersEF, Kools PF, Mols R, KazmierczakB, BartnitzkeS, BullerdiekJ, Dal Cin P, De Jong PI, Van den BergheH, Van de Ven WJ (1 994): Physicalmappingof chromosome1% breakpoints in lipoma, pleomorphicsalivary gland adenoma. uterine leiomyoma,and myxoid liposarcoma. Genomics 20:210-222. SchwendelA, LangreckH, ReichelM,SchrockE, R i d T, DietelM, PetersenI (1997): Primarysmallcell lung carcinomasand their metastasesare characterizedby a recurrentpatternof genetic alterations.Int J Cancer 74:8&93. ShibataT, Uryu S, Kokubu A, Hosoda F, Ohki M, SakiyamaT, MatsunoY, TsuchiyaR, Kanai Y, KondoT, ImotoI, InazawaJ. HirohashiS (2005): Geneticclassification.oflung adenocarcinoma based on array-basedcomparativegenomic hybridizationanalysis:its associationwith clinicopathologicfeatures.Clin Cancer Res 11:61774185. Simon F, JohnenG, KrismannM, Muller KM (2005): Chromosomalalterationsin early stages of malignantmesotheliomas.VirchowsArch 447:762-767. Slebos RJ, Livanos E, Yim HW, Randell SH, ParsonsAM, DetterbeckFC, Rivera MP, Taylor JA (2005): Chromosomalabnormalitiesin bronchialepitheliumfromsmokers,nonsmokers,andlung cancerpatients.Cancer Genet Cytogenet 159:137-142. Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, IshikawaS, FujiwaraS, WatanabeH, KurashinaK, HatanakaH, BandoM, OhnoS, IshikawaY, AburataniH,Niki T, SoharaY,Sugiyama Y,Mano H (2007): Identificationof the transformingEML4-ALKfusion gene in non-small-cell lung cancer.Nature 448561-566. Struski S, Doco-Fenzy M, Comillet-LefebvreP (2002): Compilationof published comparative genomic hybridizationstudies. Cancer Genet Cytogenet 135:63-90. Sun S , SchillerJH, GazdarAF (2007): Lung cancerin never smokers-a differentdisease.Nut Rev Cancer 7:778-790.

REFERENCES

427

Sy SM, Wong N, Lee TW,Tse G,Mok TS, FanB. PangE, JohnsonPJ, Yim A (2004): Distinct patterns of genetic alterationsin adenocarcinomaand squamouscell carcinomaof the lung. EurJ Cancer 40: I 082- 1094. Tai AL, Yan WS, Fang Y, Xie D, Sham JS, Guan XY (2004): Recurrentchromosomal imbalancesin nonsmall cell lung carcinoma:the association between Iq amplification and tumorrecmence. Cancer 100:1918-1927. TakamochiK, OguraT,Suzuki K, KawasakiH, KurashimaY, YokoseT, Ochiai A, Nagai K, Nishiwaki Y, Esumi H (200 1 ): Loss of heterozygosityon chromosomes9q and 16p in atypical adenomatous hyperplasiaconcomitantwith adenocarcinomaof the lung. Am J Puthol 159 1941-1948. TakanamiI (2005): The prognostic value of overexpressionof Skp2 mRNA in non-small cell lung cancer. Oncol Rep 13:727-73 I. TaniguchiT, KarnanS, Fukui T, YokoyamaT, Tagawa H, Yokoi K. Ueda Y, Mitsudomi T, Horio Y, HidaT, YatabeY, Set0 M, Sekido Y (2007): Genomicprofilingof malignantpleuralmesothelioma with array-basedcomparativegenomic hybridizationshows frequentnon-randomchromosomal alterationregions including JUN amplificationon lp32. CancerSci 9k438-446. TiainenM, TammilehtoL, MattsonK, KnuutilaS ( 1 988): Nonrandomchromosomalabnormalitiesin malignantpleural mesothelioma. CancerGenet Cytogenet 33:25 1-274. Tiainen M,Tammilehto L, Rautonen J, Tuomi T, Mattson K. Knuutila S (1989): Chromosomal abnormalitiesand their correlationswith asbestos exposure and survival in patients with mesothelioma. Br J Cancer60:618-626. Tonon G, Wong KK, Maulik G,BrennanC, Feng B, Zhang Y, KhatryDB, ProtopopovA, You MJ, Aguirre AJ. Martin Es. Yang Z, Ji H,Chin L, Depinho RA (2005a): High-resolution genomic profiles of human lung cancer. Proc Nut1AcaJ Sci USA 102:9625-9630. Tonon G, BrennanC, ProtopopovA, Maulik G, Feng B, Zhang Y, KhatryDB, You MJ, AguirreAJ, Martin ES. Yang Z, Ji H, Chin L, Wong KK, Depinho RA (2005b): Common and contrasting genomic profiles among the majorhuman lung cancer subtypes. ColdSpring HurbSymp Quunt B i o l 7 0 1 1-24. TorenbeekR. HermsenMA, MeijerGA, BaakJP,MeijerCJ( 1999):Analysis by comparativegenomic hybridizationof epithelial and spindle cell components in sarcomatoidcarcinomaand carcinosarcoma: histogenetic aspects. J Puthol 189:33&343. Toyooka S, Toyooka KO, MaruyamaR, VirmaniAK, GirardL, MiyajimaK, HaradaK, Ariyoshi Y, TakahashiT, Sugio K, BrambillaE, GilcreaseM, MinnaJD, GazdarAF (2001): DNA methylation profiles of lung tumors.Mol Cancer Ther 1 5 - 6 7 . Ullmann R, Schwendel A, Klemen H, Wolf G, Petersen I, Popper HH (1998): Unbalanced chromosomal aberrationsin neuroendocrinelung tumors as detected by comparativegenomic hybridization.Hum Puthol29:I145-1 149. Ullmann R, Petzmann S, Sharma A, Cagle PT, Popper HH (2001): Chromosomal aberrationsin a series of large-cell neuroendocrinecarcinomas:unexpecteddivergencefrom small-cell carcinoma of the lung. Hum Path01321059-1063. Varella-GarciaM, Chen L, Powell RL,Hirsch FR, Kennedy TC, Keith R, Miller YE, Mitchell JD, Franklin WA (2007): Spectral karyotyping detects chromosome damage in bronchial cells of smokers and patients with cancer. Am J Respir Crit CareMed 176:505-512. WalchAK, ZitzelsbergerHF,Aubele MM, MattisAE, BauchingerM,CandidusS,PrauerHW, Werner M, Hofler H (1998):Typical and atypical carcinoid tumorsof the lung are characterizedby 1 Iq deletions as detected by comparativegenomic hybridization.Am J Pathol 153:1089-1098. WangYC, Hsu HS, Chen Tp,ChenJT(2006): Moleculardiagnosticmarkersfor lungcancerin sputum and plasma. Ann N Y Acud Sci 1075:179-184. WeirBA, Woo MS, Getz G, PernerS, Ding L, BeroukhimR, Lin WM,ProvinceMA, KrajaA, Johnson LA, Shah K, Sat0 M, Thomas RK, BarlettaJA, Borecki IB, BroderickS, Chang AC, ChiangDY,

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ChirieacLR, ChoJ, Fujii Y,GazdarAF, GiordanoT,GreulichH, HannaM, JohnsonBE, Kris MG, Lash A, Lin L, Lindeman N, Mardis ER, McPherson JD, Minna JD, Morgan MB, Nadel M, OrringerMB, OsborneJR, OzenbergerB, Ramos AH, Robinson J, Roth JA, Rusch V, Sasaki H, ShepherdF, Sougnez C, Spitz MR, Tsao MS, Twomey D, VerhaakRG, WeinstockGM, Wheeler DA, WincklerW, YoshizawaA. Yu S, Zakowski MF, ZhangQ, Beer DG, WistubaTI, WatsonMA, GarrawayLA, Ladanyi M,Travis WD, Pa0 W, Rubin MA, Gabriel SB, Gibbs RA, VarmusHE, Wilson RK, Lander ES, Meyerson M (2007): Characterizing the cancer genome in lung adenocarcinoma.Nature 450:893-898. Whang-PengJ, Kao-ShanCS, Lee EC, Bunn PA, CarneyDN, GazdarAF, MinnaJD (1 982): Specific chromosomedefect associated with human small-cell lung cancer; deletion 3p( 14-23). Science 215: 18 1-182. WikmanH, KettunenE (2006): Regulationof the G L/S phaseof thecell cycle andalterationsin the RJ3 pathway in human lung cancer. ExpertRev Anticancer Ther 6:5 15-530. Wikman H, Nymark P, VayrynenA, JarmalaiteS, Kallioniemi A, Salmenkivi K, Vainio-SiukolaK, Husgafvel-PursiainenK, KnuutilaS, Wolf M, AnttilaS (2005): CDK4is a probabletargetgene in a novel amplicon at 12q13.3-ql4.1 in lung cancer. Genes Chromosomes Cancer 42: 193-199. Wikman H, RuosaariS, NymarkP, SarhadiVK, SaharinenJ, VanhalaE, KarjalainenA, HollmCnJ, KnuutilaS, Anttila S (2007): Gene expressionand copy numberprofilingsuggests the importance of allelic imbalance in 19p in asbestos-associated lung cancer. Oncogene 26:4730-4737. Wong MP, Fung LF, Wang E, Chow WS, Chiu SW, Lam WK, Ho KK, Ma ES, Wan TS, ChungLP (2003): Chromosomal aberrationsof primary lung adenocarcinomasin nonsmokers. Cancer 97: 1263-1270. Xue X, Zhu YM, Woll PJ(2006): CirculatingDNA and lung cancer.Ann N YAcadSci 1075:154-164. Yokoi S, Yasui K, Mori M, IizasaT, FujisawaT, InazawaJ (2004): Amplificationand overexpression of SKp2areassociatedwith metastasisof non-small-cell lungcancersto lymphnodes.AmJ Pathol 165:175-1 80. ZanazziC, HersmusR, Veltman IM. Gillis AJ, van DrunenE, Beverloo HB, HegmansJP,VenveijM, LambrechtBN, OosterhuisJW, Looijenga LH (2007): Gene expression profilingand gene copynumberchangesin malignantmesotheliomacell lines. Genes Chromosomes Cancer 465395-908. ZhaoJ, de KrijgerRR, Meier D, Speel El,SaremaslaniP, Muletta-FeurerS, MatterC. Roth J, Heitz PU, KomminothP (2000): Genomic alterationsin well-differentiatedgastrointestinaland bronchial neuroendocrinetumors (carcinoids): markeddifferences indicating diversity in molecular * pathogenesis. Am J Pathol 157:1431-1438.

Tumors of the Digestive Tract GEORGIA BARD1 and SVERRE HElM

Althoughmore than 30 years have passed since the firstchromosomebandinganalysisof humancolonic polyps (Mitelmanet al., 1974), ourcytogeneticknowledgeaboutdigestive tracttumorsis still disproportionatelylimited.These tumors(totaling 1100 at the time of writing)makeup no morethan4%of all the cases with abnormalkaryotypesincludedin the databaseof chromosomeaberrationsin cancer (Mitelmanet al., 2008).

LARGE INTESTINE Colorectalcancer, with adenocarcinomasas the dominanttumortype, is one of the most common malignanciesin largepartsof the world and one whose incidenceis rising.Most colorectaladenocarcinomasdevelopfrombenign,polyp-likeadenomasin whatis calledthe adenoma-carcinoma sequence (Bedenne et al., 1992). The fact that macroscopically recognizable,sometimes symptomatic,premalignantmucosa lesions exist opens up the unique possibility in this organ system to investigateand compare all main stages of carcinogenesis:the benign but malignancy-proneadenomas,the locally infiltratingcarcinoma, and the metastatic lesions. In addition, the circumstancethat a relatively large proportionof colore'ctalcancers,perhaps10-15% (Houlstonet al., 1992),is familialmakes it possible to compare the pathogeneticevents that characterizehereditaryand sporadic' tumors. In spiteof themoredetailedunderstanding of thecellularandmoleculareventsunderlying colorectalcarcinogenesisobtainedin recentyears,the average5-yearsurvivalrateof patients sufferingfromthis diseaseremainsabout40%(Leslie et al., 2002). Althoughsome increase in survivalforpatientswith metastaticdiseaseis now beingregistereddueto the introduction of biological therapies(Van Cutsemet al., 2006), it is neverthelessclear thatthe extensive new knowledge about the structure,function,and interactionof key genes in large bowel tumorigenesishas notyet broughtaboutcorrespondingimprovementsin theclinicalhandling of patients,especially as regardsthe sporadictype that constitutesmore than 85% of all colorectalcancers.The reasonsfor this areundoubtedlycomplex,but one aspectmay, in our opinion,be a widespreadlack of appreciationof the full extentof the geneticcomplexityand heterogeneitythat characterizecolorectalmalignanttumors.The vast majorityof studies Cancer Cytogenetics, Third Edition. edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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seeking to unravel the acquiredgenomic changes of large bowel tumorcells were often unnecessarilyreductionistic(Heim, 1992), focusing exclusively on gene-level alterations without taking into account the numerouscoexisting genomic abnormalitiesat higher organizationallevels, in particularnumericaland structuralchromosomalabnormalities, and without due recognitionof the extensive cell-to-cell variationseen in the neoplastic parenchyma.In only few studies (Briiderleinet al., 1990; Platzer et al., 2002; Cardoso et al., 2007) were genetic methodologies combined to provide simultaneous,detailed informationaboutchanges at the gene level and a global overviewof the genomic profile in individualtumors,let alone in individualcells withinthattumor.In addition,most series of geneticallycharacterizedcolorectalcancersare insufficientlyaccuratewhen it comes to the clinical and histopathologicaldescriptionof the tumors.Finally,very few attemptshave been made to prepare for meta-analysis genetic information about colorectal tumors obtainedby differentgroupsof researchers,even whenthey utilizedthe samemethodological approach. In total,less than 550 tumorsof the largeintestinewith clonal chromosomeaberrations aredescribedin the cytogeneticliterature(Mitelmanet al., 2008). The mainreasonfor the paucityof datais unquestionablythe sameas formost solid tumors;it hasbeen very difficult to induce the tumorcells to divide in vitro, and often the metaphaseshave been of low technicalquality,makinginterpretations unreliable.A particulardifficultywith largebowel tumorsis the high tendency for infections to develop in the cultures.All these problems notwithstanding,thedatathathavecome forththe last two decadeshavemadeit possibleto constructa relativelydetailedpictureof the cytogeneticeventsof bothbenignandmalignant colorectaltumorigenesis.The cytogeneticinvestigationshave helped ( 1) to identify early, possibly initiating,genetic events in colorectaltumorigenesis;(2) to determinethe clonal relationshipamongsynchronouslygrowing,macroscopicallydistinctcolorectaladenomas as well as betweencarcinomasand polyps growingin the same patient;(3) to describethe cytogeneticmake-upof metastaticlesionsby comparingkaryotypicallyprimarytumorsand their local and distal metastasesin individualpatients;(4) to demonstrateconsiderable geneticheterogeneityin colorectaltumorswith distinctcytogeneticsubgroupscorresponding to at leasttwo oncogeneticpathwaysin sporadiclargebowel cancer,as is knownto be the case also in hereditarycolorectaltumors;and (5) to reveal a tightcorrelationof both the oiierall karyotypic patternand of specific chromosome alterationswith prognosis for colorectal cancer patients. The latter observationsare still not widely appreciated,but they do providevaluableand in some instancesuniqueinformationaboutthe likely clinical outcome and, hence, may come to serve as clues to how colorectalcancerpatientsshould best be treated.

COLORECTAL TUMORS ARE CHARACTERIZED BY RECURRENT CHROMOSOME ABERRATIONS Of the more than 500 cytogeneticallyabnormalcolorectal tumorspublished, 139 were classified as adenomas,338 were adenocarcinomas,and 45 were listed as carcinomasnot otherwise specified. Clonal chromosomeaberrationswere detected in nearly 40%of the nonadenomatouspolyps, in 80%of the adenomas,in up to 90%of the primarycarcinomas, and in all the metastaticcancersreported. The systematic cytogenetic studies behind these numbershave provided important information that in part corroboratesand extends the molecular genetic model of

COLORECTALTUMORS ARE CHARACTERIZED BY RECURRENT CHROMOSOME ABERRATIONS

431

colorectal carcinogenesisproposedby Fearon and Vogelstein ( 1990). Some discoveries have been unexpected,however, and have yielded novel insights into the processes of initiation and progressionof colorectal cancer. The main conclusion reached by karyotyping analysis of colorectal neoplastic cells is that both benign and malignant neoplastic lesions of the large intestine display characteristic patterns of acquired chromosomalabnormalities.No single cytogenetic aberrationcan be said to distinguish colorectal adenomas from carcinomaswith absolute certainty;however, in groupwise comparisons, adenomas come across as karyotypically much more simple than their malignantcounterparts. The developmentof a wide arrayof fluorescencein situ hybridization(FISH)-based techniques in recent years has enabled a marriageof conventionalcytogenetics with molecular genetics, and the resulting molecular cytogenetic techniques have greatly facilitatedthe genetic analysis of colorectal tumors.In particular,comparativegenomic hybridization(CGH) studies on metaphases(chromosomalor cCGH) or utilizing array technology(aCGH)have been performedon severalseries of colorectaltumorsconsisting of adenomas,primarycarcinomas,andmetastases.The DNA copy numberpatternrevealed by cCGH and aCGH analyses has substantiallycontributedto our understandingof the cytogeneticsof colorectalcarcinogenesis,confirmingthe overallpicturearrivedat on the basis of karyotypingstudiesalone and expandingit by detectingalso genomic imbalances that are below the detectionlimit of karyotyping.

Colorectal Carcinomas Inall majorpublishedseriesof cytogeneticallyinvestigatedcolorectalcarcinomas(Reichman etal., I981;Mulerisetal.,1990;Konstantinovaetat., 1991;Bardietal.,1993a,1993b,1995a), clonal aberrationswere found in the vast majorityof cases. However,a small fractionof tumors,perhapslo%,do appearto have a normalchromosomecomplement.Some of these tumorsmay have only submicroscopicgenomicrearrangementsor the examinedcells may havebeen of stromalorigin;once acell entersmitosisandis takenthroughthe stepsnecessary forchromosomeanalysis,it is no longerpossibleto determineits phenotype.Thatstromalor normalepithelialadmixturein primaryculturesof colorectalcarcinomasrepresentsa real problemis evidentfromthe factthatthegrowthfractionof tumorparenchymacells may be as low as 2%(Shroyet al., 1988).At leastto someextentthisproblemcanbe overcome,however, as demonstratedby theincreasedpercentageof cytogeneticallyabnormalcasesseen whenthe culturingtechniquesare optimized. The modal chromosomenumberof colorectal carcinomasdisplayingclonal chromosome aberrationsvaries from hypo- or near-diploidto near-pentaploid.More thanhalf of the cases have had near-diploidor pseudodiploidkaryotypes,which is consistentwith the findingof diploidy in severalDNA flow cytometrystudiesin as muchas 47-54% (Nishida et al., 1995; Tonouchiet al., 1998; Lin et al., 2003). Admittedly,among flow cytometricallynormalcases, theremay not only be tumorswith normalkaryotypesor one or few numerical and/or structural changes, but also tumors with extensive chromosomal rearrangementsleadingto no oronly smallchangesin the total DNA content.Carcinomas with a near-triploidchromosome number usually have both numerical and structurd rearrangements, althougha few such tumorswith numericalabnormalitiesonly havebeen described. When all reportedcases with clonal aberrationsare pooled, it turnsout thatalthougha certain difference in the reportedfrequenciesis apparent,the most common numerical

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150 1

2 3 4 5 6 7 8 9 10 1 1 12 13 14 15 16 17 18 19 20 21 22 X Y

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FIGURE 13.1 Distribution of numerical chromosome aberrations in 338 colorectal adenocarcinomas with clonal chromosome aberrations.

aberrations(Fig. 13.1) are monosomy 18 and trisomy 7, followed in decreasingorderof frequencyby trisomy 13, monosomy 14,trisomy20, and monosomyforchromosomes22,4, and 21. Withthe exceptionof the Y, all chromosomeshave been seen to be involved in structural rearrangementsin colorectal carcinomas. The breakpointsrecurrentlyinvolved in such rearrangementsmap to no less than 160 chromosomebands, but at variablefrequenciesin differentstudies.However,when all dataavailablein the literatureareconsidered,the most markedclusteringof breakpointsis seen at 8q10, 17q10, and 13q10, followed by lq10, 5p10,7p10, 17pl I , 1 7 ~ 1 2and , 18q21 (Fig. 13.2). Severalotherchromosomalbreakpoints 45 40

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COLORECTALTUMORS ARE CHARACTERIZED BY RECURRENT CHROMOSOMEABERRATIONS

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FIGURE 13.3 i(S)(qlO) and i(17)(qlO) are the most frequent (10%)structural chromosome aberrations in colorectal adenocarcinomas.

are also recurrentlyinvolved but in less than 3% of the total numberof cytogenetically examinedcolorectalcarcinomas. The most frequentstructuralrearrangements in the total materialarei(S)(q10) andi( 17) (q10) (Fig. 13.3) foundin aboutlo%,followedbydel(l7)(pI1 orpl2)(8%), and i(13)(q10) is loss of 8p andgain anddel( I8)(q21) (5%each).The net outcomeof theserearrangements of 8q,gain of 13q, loss of 17p, and gain of 17q. Although the aforementionedanomalies were seen repeatedly in all major published series of cytogenetically characterized colorectal carcinomas,the reportedfrequenciesvaried considerably.Technicaland stochastic factors undoubtedlyplay a role in bringingabout this variability,but systematic differencesrelatedto the compositionof the series examinedcould also be important,in particularwith regardto possible etiologic andpathogeneticdifferences,includingmicrosatellite versus chromosomalinstabilitystatus,among differentgroupsof patients. The consistentlosses of genomic materialin colorectalcancerpresumablyexert their pathogeneticinfluencethroughloss of tumorsuppressorgenes (TSG),butthe effect of gains remainselusive, even for genomic loci undergoingamplification.Using combinedCGH and DNA microarrayexpressionprofiling,Platzeret al. (2002) examinedthe expressionof over 2000 genes situatedon chromosomeanns7p, 8q, 13q, and2Oq, thatis, genomicareas which in their study were consistentlyfound amplified in metastaticcolorectalcancers. Lnterestingly,96.2% of the genes located in areasof chromosomeamplificationdid not show upregulationof expression.On the otherhand,Cardosoet al. (2007), who attempted an integrationof genomicandexpressionprofilingdataof colorectalcanceravailablein the public domain,found that several aneuploidloci were associatedwith differentialregulation of specific genes. In particular,losses of 4q21-35, 5q31-32, 14q32, 17~12-13, 17q23-25, 18q21, 19~13,and 22q13, and gains of 7p15-22, 7q22-32, 8pll-21, 8qll-24, 13q12-13, 2Op12-13, and 2Oq11-13 identifiedclustersof genes reportedto be, respectively,down- and upregulatedby expression analysis. However, in some instances, such as for the SlOOP gene in 4p16, SPARCin 5q31-32, andSOX9 in 17q24-25, the nature of the aneuploidyevents and the directionof the correspondinggene expressionchanges were apparentlydiscordant.That only a proportionof genes undergoingcopy number changesbecauseof aneuploidyeventsappearto be differentiallyexpressedcan be attributed to a number of mechanisms responsible for normal and abnormal control of gene

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TUMORS OF THE DIGESTIVETRACT

expression, such as mutation, methylation, and micro-RNA expression. Nevertheless, recurrentgenomic imbalancesin colorectalcancer apparentlydo affect gene expression, albeit in a mannerthat is not easy to predict, and doubtlessly also the biology of the malignantcells that make up the tumor.

Colorectal Adenomatous and Hyperplastic Polyps Chromosomeaberrationshave now been reportedin nearly 140 such adenomas.The early studiesleft the impressionthat gains of whole chromosomeswere the only, or at least the predominant,aberrations.As data from new and largerseries were added,the consensus picture of the karyotypic characteristicsof benign colorectal tumors has undergone considerablerefinements.According to Bardi et al. (1993~)and Bomme et al. (1994, 1996a), who karyotyped82 colorectalpolyps, up to 80%of large bowel adenomascarry clonal chromosomeaberrations.Otherinvestigatorshave reportedlower percentagesof cytogeneticallyabnormallesions, from30%to 50%.In all series,however,mostkaryotypically abnormalpolyps(90%)had only few cytogeneticabnormalitiesgiving rise to pseudoor near-diploidkaryotypes.The remainderare near-triploidor near-tetraploid with massive chromosomechanges, often showing anomaliesthat are recurrentin colorectaladenocarcinomasas well. At present,therefore,one cannotpointto any singlekaryotypicfeaturethat is capable of distinguishing unequivocally between benign and malignant colorectal tumors.As a group, the adenomashave much simpler karyotypes. The most frequentchromosomeabnormalityin colorectalpolyps is 7, foundin 50% of all reportedcases (Fig. 13.4) andmostly as the sole anomaly.Althoughthe pathogenetic relevanceof +7 in large bowel neoplasms as well as tumorsof other tissues has been questioned(Bardiet al., 199 la; Johanssonet al., 1993), the finding of this trisomyin the epithelial componentof adenomatouspolyps (Bardi et al., 1995b; Bomme et al., 1994, 1996a, 1996b, 2001) by chromosome banding analysis of metaphase cells and by interphaseFISH analysis with centromere-specificprobes supportsthe early suggestion that it plays a primaryrole in some colorectal neoplasms. At genomic loci frequently foundto be gainedin aCGHstudies,at least fivegenes mappingto 7p22.3,7p15.2,7q22.I ,

+

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Chromosome FIGURE 13.4 Distribution of numerical chromosome aberrations in 139 adenomas of the large intestine with clonal chromosome aberrations.

COLORECTALTUMORSARE CHARACTERIZED BY RECURRENT CHROMOSOME ABERRATIONS

435

7q21.3, and 7q32.3, that is, EIF3S9, CBX3, AZGPI, COLlA2, and IMPDHI, have been reportedin two ormoreindependentstudiesto be upregulatedin colorectaladenomasand carcinomas compared with normal colon mucosa (Cardoso et al., 2007). EIF3S9 is involved in protein biosynthesis, CBX3 and IMPDHI in nucleic acid metabolism,and AZGPI and COLIA2 in cell adhesionprocesses. However,the pathogeneticinvolvement of theseorothergenes all alongchromosome7 in the initiationof colorectaltumorigenesis is still speculative, as is indeed the mechanism by which the presence of any extra chromosomecopy might translateinto a shift in growthpotentialsufficientto precipitate neoplastic transformation. Gain of chromosome 13 is the second most common numericalabnormalityin large bowel adenomasandhasbeenfoundin about30%of thecases (Fig. 13.4).The GTF3A and HMGBl genes, mapped to 13q12.3- 13.1 and 13q12, respectively,have been reported in more than two independentstudies to be differentially expressed (upregulated)in colorectal adenomas (Cardoso et al., 2007). Gain of chromosome 20 has been found in 22% of the cases (Fig. 13.4). Frequentgains of at least six distinctgenomic loci at both the p and the q arm of chromosome 20 have been identified also by CGH analysis. The CDC25B gene at 2Op13, involved in proteinamino acid phosphorylation,as well as AHCY, localized at 2Oq10-13.1, relatedto 1-carboncompoundmetabolism,have both been reportedas differentiallyexpressed (upregulated)in colorectal adenomasin more thanthreeindependentstudies. Otherfrequentaneusomiesin colorectaladenomasare, in decreasingorderof frequency,loss of chromosome18 ( 15%)and gain of chromosomes8 and 9, each seen in 10% of the cases (Fig. 13.4). The necessity to culturethe tumorcells priorto bandinginvestigationandalso the fact that differentclones are likely to entermitosis at differentrates,reduce the information valueof cytogenetic analysisregardingthe presenceandrelativesize in vivo of clones with numerical changes. To estimate more reliably the clonal composition of colorectal adenomas, Bomme et al. (2001) performedinterphaseFISH analyses with probes for chromosomes1,7, 13, and 20 on a series of previouslykaryotypedadenomas.Gains of chromosomes7, 13, and 20 were found in 3 2 4 4 % of the adenomas,verifying that these trisomiesareindeedcommonandthatthey occurin vivo. Althoughgain of chromosome7 usually precededthe othergains in those instanceswherethis could be assessed, this was not always so. Evidently,the end resultof the acquiredchromosomalimbalancesrather than the sequence in which they occur is of the essence in colorectal tumorigenesis. A deletion of part of the shortarm of chromosome 1 (Fig. 13.5) is the most common structuralrearrangementin intestinalpolyps. We have seen it in 30% of all cases with an abnormalkaryotype,often as the only anomaly,which led us to suggestthatthis is an early, possibly primary, genetic change in the development of large bowel tumors (Bardi et al., 3993b). Very recently, in a genome-wide single nucleotide polymorphism(SNP) analysisof 78 rectaltumorsof differentclinical stages,Lips et al. (2007) identifiedloss of lp36 in 26%of the investigatedadenomas;they too concludedthatit was an earlyeventas it was not seen more frequentlyin carcinomasanalyzedby the same approach. The consistencyand extent of the l p loss in colorectaladenomaswas also investigated using a combinedcytogeneticand moleculargenetic approach(Bomme et al., 1998). The deletions were shown to be interstitialwith a minimal common deleted region between markersDlS199 and DIS234 in bands lp35-36 (Fig. 13.5). suggestingthat this might be the site of the hypotheticaltumorsuppressorgene presumedto be lost by the deletion.This genomic area contains the human homologue of the tumor modifier gene Mom1 ( I p35-36. I) which, in mice, modifiesthe numberof intestinaltumorsin multipleintestinal

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TUMORS OF THE DIGESTIVE TRACT

1

1:

‘14 1

3

2

FIGURE13.5 Partialkaryotypesof chromosomeI fromsix benign colon lesions with 1p deletions of varioussize. In theideogramof chromosome I (right),the size of the deletedsegment is illustrated for each case. The minimumcommon deleted region is band lp36.

neoplasia(MIN)-mutatedanimals.Thatdistal Ip is indeed importantin colorectaltumorigenesis was shown functionally by Tanaka et al. (1993), who demonstratedthat the introductionof a normal lp36 segment into a colorectalcarcinomacell line renderedit nontumorigenic. More thanone-thirdof all investigatedhyperplasticlarge bowel polyps, that is, lesions withoutanycellularatypia,have been shownto harborclonal chromosomalabnormalities. Whetherthese polyps, too, have a tendencyto progresstowardcarcinomasis not yet clear, but the cytogenetic data unequivocally indicate that they are genuine neoplasms with karyotypicfeaturessimilarto those of small tubularadenomas.Rashidet al. (2000), in a genotype-phenotype retrospectiveanalysis of 1 29 hyperplasticpolyps, identifiedallelic loss of l p (1~32-36)as the most frequentgenetic alteration.In that series, interestingly, some patientswith 1p allelic loss had hyperplasticpolyposis (more than 20 hyperplastic polyps) and some of them had family members with colorectal cancer. The authors suggestedthat lp loss could be the “startingpoint”of a hyperplasticpolyp-adenocarcinoma sequence. Deletions of the short arm of chromosome 1 are also seen in large bowel carcinomas although, relatively speaking,not as frequentlyas in adenomasand often with a larger

CLONALRELATIONSHIPAMONG SYNCHRONOUSLYGROWINGCOLORECTALTUMORS

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segmentlost. Usually the del(Ip)in carcinomasis accompaniedby severalotheranomalies, butcases also exist in which it was the only karyotypicchange.Rests of adenomatoustissue werethenoften foundin the tumors,and it hasbeen suggestedthatthe cells showingdel(lp) as the only anomaly actuallygrew from these remnants(Bardiet al., 1995a). Based on the findingin an allelic imbalancestudythatcolorectalcarcinomaslacking 1p deletionin theprimarytumoracquiredsuchchangesin theirmetastaticlesions, Thorstensen et al. (2000)suggestedthatloss of I p35-36 is of importancebothearlyand late in colorectal tumorigenesis.We sharethe view expressedby Couturier-Turpin et al. (200 1) thatone needs to distinguishbetween loss of I p occurringin pseudodiploidcells, mostly as the sole cytogeneticchangethatappearsto be of importancein the initiationof carcinogenesis,and theloss of I p thatis oftenfoundin massivelyaneuploidcells, in whichcase thedeletionmay have been acquiredas a resultof complex chromosomalrearrangements occurringduring tumorprogression.

CLONAL RELATIONSHIP AMONG SYNCHRONOUSLY GROWING COLORECTAL TUMORS Synchronous Adenomas The phenotypicprogressionof colorectaltumorsis drivenby theirstep-by-stepacquisition of genomicalterationswhichnot only signify importantchangesin carcinogenesis,butalso constitutehighly informativemarkersof tumorclonality.In a seriesof 24 adenomasfrom 1 1 patients,chromosomebandmganalysiswas used to examinethe clonalrelationshipamong synchronouslygrowing, macroscopicallydistinct colorectal adenomas (Bomme et al., 1996a). The main question to be answered was whether these polyps had karyotypic similarities or whether the clonal findings were unrelated,indicating that they arose independently.In six patients,similar clones were found in separatepolyps within the same patient,polyps that were always located in the same partof the largebowel. In the remainingtwo patients,both with one rectal adenomaand one adenomain the colon, no karyotypic similarity between the lesions was seen. The findings indicate that when macroscopicallydistinct,synchronousadenomasare growingin the same partof the large bowel, they are karyotypicallysimilar,in contrastto when they grow in differentparts (proximal colon, sigmoid, and rectum). In the former situation, two explanationsare possible.Eitherthe sameetiologic agenthaselicited identicalpathogeneticresponsesfrom several cells within the same anatomicalarea (i.e., they have acquiredthe same chromosomal aberration,probablybecause that particularetiologic stimulustends to induce one andthe same genomicresponse),or the morphologicallydistinctbutclose adenomasarein fact seemingly separatelesions belongingto the same clone of neoplasticallytransformed cells. In the latter situation,on the other hand, they are macroscopicmanifestationsof parallelbut pathogeneticallyindependentneoplasticprocesses. The latterhypothesiscan also explain the by and largecommonloss of heterozygocity(LOH) featuresidentifiedin 7-1 3 adenomasfromeach of seven patientswith sporadiccolorectalcancerexaminedin a recent genome-wide allelotypinganalysis by Mao et al. (2006).

Synchronous Polyps and Carcinomas Many colorectalcarcinomasarisefromvisible benignprecursorlesions, adenomas,in what has been termedthe adenoma+xwinomasequence(Bedenneet al., 1992). Most adenomas

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TUMORS OF THE DIGESTIVE TRACT

do not transformmalignantly,however,in spiteof the dysplasticchangescharacterizingtheir epithelialcomponent.Othercarcinomasarise de now, that is, without a visible precursor lesion. In additionto adenomas,hyperplasticpolyps are tumorousyet benign, and in most instancespresumablynon-neoplastic,lesions frequentlyseen in the colon and rectum.The identificationof geneticsimilaritiesanddifferencesbetweenadenomasandcarcinomas,and also between polyps thattend to and those that do not tend to transformto malignancy,is likely to shed light on the mechanismsdrivingtumorigenesisin the large intestine.The developmentalrelationshipamongvarioustumorlesionspresentatthe sametime in the same patientis anotherinterestingissue; are they clonally relatedor not? To approachthese questions, 30 tumorlesions of the large bowel, includingcarcinomas, adenomas,and non-adenomatouspolyps, from seven patientswith colorectalcancer were cytogenetically analyzed (Bardiet al., 1997a). Clonal chromosomalabnormalities were found in all adenomasand carcinomasbut only in 37.5% of the non-adenomatous polyps. Although the majorityof hyperplasticpolyps displayed a normalchromosome complement,some showed clonal aberrationsthat in general seemed to be simplerthan those of dysplastic polyps. It is possible that the subset of hyperplasticpolyps with cytogenetic aberrationsmay have had small dysplastic areas that went undetectedby conventionalhistological examination,or the chromosomeaberrationsthey carry,which are indistinguishablefromthose of small tubularadenomas,arenot dysplasia-specificbut rather related to the hyperproliferationin the intestinal mucosa. Finally, the very occurrence of clonal chromosome aberrationsin a proportionof hyperplasticpolyps, which constitutesstrongevidence thatthese lesions areneoplastic,couldbe viewed as the genetic corollary of a hyperplasticpolypcarcinomasequence even in the absence of correspondinghistopathologicalorclinical indicationsto this effect. Leggettet al. (2001) confirmedourearlierconclusion thatsome hyperplasticpolyps do have acquiredgenetic changes by findingmicrosatellitcinstability in three and KRAS mutationsin eight of 47 hyperplasticpolyps examined. Although some chromosome aberrationshave been found in carcinomas but not in adenomas,for example der(8;17)(qlO;qlO),indicating that they may be specifically associatedwith malignanttransformationof large bowel mucosa,adenomas,and carcinomas occurring simultaneouslyin the same patient by and large share most of their chromosomalfeatures(Bardiet al., 1997a). This karyotypicsimilaritybetween malignant and benigntumorsin the same patient,and also sometimesamongnonmalignantpolyps in the same individual(Fig. 13.6), can be interpretedto indicate that the macroscopically distinctlesions aroseas partof a singleclonal expansion,in spiteof the factthatthe distance betweenthem was morethan3 cm. The only alternativeexplanationwould be thatthe same oncogenetic environmentalfactor(s) induced identical chromosomalrearrangementsin more than one cell. Ried et al. (1996) used CGH to confirm that the frequency and degree of genetic aberrationsincreases with progression from low-grade adenoma through high-grade adenomato carcinoma.Only three of their 14 low-gradeand five high-gradeadenomas showed chromosomeabnormalitiesby CGH, comparedwith 14 of 16 carcinomas.The most frequentlygained chromosomeregions were 2Oq, 13q, 8q, 7p, and 7q, whereas frequentlosses were observedfrom 8p, 18q, 4q, and 17p. Furthermore,the frequencyof specific alterationsincreased with advancing stages of tumor progression.Also Meijer et al. (1 998) found that the averagenumberof chromosomalaberrationsincreasedfrom adenomato carcinoma;frequentgains involved I3q, 7p, 7q, 8q, and 20q and losses most often occurredat I8q, 4q, and 8p. The resultsof CGH analysis in these studiesthus are in

CLONAL RELATIONSHIPAMONG SYNCHRONOUSLY GROWING COLORECTALTUMORS

Case I

~ ~ U H P W T1

case 111

case 11

T2

del(IXp36)

439

T2

T4

Y17Xq10)

T1

T2

FIGURE 13.6 Ideograms and partial karyotypes illustrating three structural chromosome abemtions, each detected in two macroscopically distinct colorectal tumors from the same patient: del( 1 ) (PI 3) was found in a carcinoma (TI) and a hyperplastic polyp (T2) from the same patient (Case I); del (l)(p36) was found in two of several tubulovillousadenomas (T2 and T4) from the same patient (Case 11): and i( 17)(q10) was found in a carcinoma (TI) and a tubular adenoma (T2) from the same patient (Case In).

almost complete accordance with the pattern of imbalances previously detected in colorectal adenomasand carcinomasby G-bandinganalysis. Only losses of 4q, which were maybehiddenin unidentifiedchromosomemarkers,appearedto be underestimatedin G-bandingstudiescomparedto the CGHdataon colorectalcancer.Ln spite of the similar findings,however,one shouldkeep in mindwhile interpretingthe combinedG-bandingand CGH results that CGH can only detect DNA copy numberchanges that are presentin at least 50%of the examined tumor cell population. Karyotypicanalysis is in this sense superiorbecauseit can also detectbalancedchangesandvery small clones consistingof as little as two abnormalmitoses. Integratingkaryotypicand CGH data,Gradeet al. (2006) recently proposeda chromosomeaberration-based progressionmodel of colorectalcarcinogenesis. In their scheme, the progressionfrom low-gradecolorectaladenomasto highgrade adenomasis accompaniedby gains of chromosome7 and chromosomearm 20q, whereasgainsof 8q and I3 as well as losses of 4p, 8p, and 18qindicatetransitionto invasive carcinomas.

Primary and Metastatic Colorectal Carcinomas Themajorcauseof deathin colorectalcanceris metastasisratherthanlocalizeddisease.It is thereforeclearthata betterunderstanding of the metastaticprocessand the findingof ways to preventit standout as primegoals in colorectalcancerresearch.Given theirimportance,it is somewhatsurprisingthatso littleis knownaboutthegeneticprofileof metastaticdeposits. As a consequence,markersof prognosisorresponseto therapyareoftenassessedagainstthe backdropof dataon the primarytumor,with the mostly implicitassumptionthatthey also reflect the situationin the secondarydisease loci. To obtain more informationon the karyotypiccharacteristicsof colorectal cancer metastases, Bardi et al. (1997b) examined cytogenetically 18 tumors from 1 1 patients with metastaticdisease. In all cases with matchedsamples from the primarytumor and lymph node metastases,cytogeneticsimilaritieswere found between the primaryand the secondarylesions, indicating that many of the chromosomalaberrationswere acquired

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TUMORS OF THE DIGESTIVE TRACT

before disease spreadingtook place. The observedgenomic similarities,combinedwith recent data showing close transcriptionalresemblance between primary tumors and metastases(D’Arrigoet al., 2005), supportthe notion that largercell clumps ratherthan raresporadiccells fromtheprimarytumorin most instancesgive riseto the secondaries.The assumedexistence of a migratingcancer stem cell (Brabletzet al., 2005) is nevertheless compatiblewith the genomic and transcriptionalsimilaritiesbetweenprimarytumorsand theirmatchingmetastasessince cancerstem cell(s) detachingfrom the primarytumorcan forma metastaticlesion with similargenomic andgene expressionpatterns.Comparedwith the primaries,the metastasesappearedto exhibitdecreasedclonal heterogeneity,probably reflectingclonal selectionwithintheprimarytumorfromwhich the metastasiswas derived, but, concurrently,an increasein the karyotypiccomplexityof individualclones (Bardiet al., 1997b).Inadditiontotheaberrationsdel(l)(p34),i(17)(qIO), -18, -21, +7,and +20, which werefoundrecurrentlyin bothprimaryandmetastaticlesions,thedel(1O)(q22)found in metastaseshas not so farbeen associatedwith primarycolorectalcarcinomas.The finding of loss of I Oq24-qterin two morecases in anotherseriesof colorectalmetastasesto the liver (Paradaet al., 1999) providesfurthersupportfor an associationbetween loss of 1Oq and tumorprogression.In a more recentLOH study,Fawole et al. (2002) used a panel of nine highly polymorphicmicrosatellitemarkersspanningthe long arm of chromosome10 to examine I 14 sporadiccolorectaladenocarcinomas.They foundthe highestLOH frequency at 10q21. I and suggested that 1Oq loss is a late event in colorectaltumorigenesis.Using CGH,Paredes-Zaglulet al. (1998) comparedthe genetic compositionof primarycolorectal tumorswithoutdistantmetastases(TNM stages1-111) with livermetastases(TNMstageIV) and founda distinctpredominanceof genetic losses in the metastaticlesions. Althoughnot all aberrationswere the same as those found by us, they too identifiedtwo patternsof alterations:(a) changes( + 8q, 13q, -4p, -8p, - 15q, - 17p, - 1 Sq, -21q, and-22q) that were more often found in liver metastasesthan in primarytumors,and (b) changes (-9q, - 1 Iq, and -17q) that were unique to the metastaticlesions. In a comparisonbetweenmultiplemetastaticlesions in the same patientbut at different sites (Bardiet al., 1997b), we could demonstratecommon karyotypicaberrationsin the lesions butnot in a singlecasewas the karyotypeof one metastaticlesion exactlyidenticalto thatof any other metastasis,even when both metastaticsampleswere from lymph nodes. Such genomic differences between primaryand secondarytumorsand among separate metastaticlesions have also been reported in several CGH studies of paired primary colorectalcarcinomasand metastasesto either lymph nodes or distantorganssuch as the liver(Al-Mullaet al., 1999;Alcock et al., 2003; Knosel et al., 2004; Gradeet al., 2006) and lung (Jiang et al., 2005; Knosel et al., 2005). However, the data are not sufficient to distinguishspecific genomic patterns,eitherchromosomalor at the gene level, that could predictor explainthe metastaticspreadingof colorectaltumorcells to particularorgansor tissues.

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CORRELATION BETWEEN KARYOTYPIC AND PHENOTYPIC FEATURES Cytogenetic Pattern and Tumor Site Colorectalcarcinomasthatariseproximal(right)ordistal(left) to the splenicflexureexhibit differencesin incidencedependingon their site and the patient’sage i d gender.Tumors in the hereditarynonpolyposis colorectal cancer (HNPCC) and familial adenomatous

CORRELATIONBETWEEN KARYOTYPICAND PHENOTYPIC FEATURES

441

polyposis (FAP) syndromesoccur predominantlyin the right and left colon, respectively, and the existence of two generalcategoriesof colorectalcancerbased on the site of origin in thelargebowel was proposedmanyyearsago (Bufill, 1990).Differencesbetweennormal right- and left-sided colonic segments that could favor progression through different tumorigenic pathways, have been recognized (Iacopetta, 2002). Right- and left-sided tumorsalso exhibit differentsensitivitiesto chemotherapy,possibly relatedto the genetic characteristicsof the tumors, with microsatelliteinstability (MSI ) phenotypesbeing associated predominantlywith right-sidedtumorsand chromosomalinstability(CIN ) with left-sided tumors (Iacopetta, 2002). Chromosomalalterationsdo not exclusively occurin microsatellitestablecolorectaltumors,however.Douglaset al. (2004) investigated 37 primarycolorectal carcinomasand 48 cell lines by aCGH and showed that CINt samples had a significantly higher number of aberrationsthan did MSI' samples, particularlygain of chromosome20 and loss of 18q and 8p. In addition,the targetof the 8q gain seemed to differ depending on microsatellitestatus with 8q24.21 frequently gained in CIN+ tumorswhereas gain of 8q24.3 occurredmore often in MSI' tumors. Microsatelliteandchromosomeinstabilityalso seem to coexist in a tumorsubset,indicating a possible interactionbetween the two mechanismsor even that a thirdgenetic pathway, different from MSl and CIN, might play a role in some colorectal cancers (Camps et al., 2006). Site-karyotypecorrelationshave largelyremainedunexaminedin cytogeneticstudiesof colorectalcancer.In our series of karyotypedtumors(Bardiet al., 1995b),we found that carcinomaslocated in the proximalcolon and rectumoften were near-diploid.with simple numericalchangesanddisplayingcytogeneticallyunrelatedclones, whereascarcinomasin the distal colon often had near-triploidto near-tetraploid karyotypeswith massivechromosomal aberrations. +

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Cytogenetic Pattern and Histology A statistically significant association was found between the karyotypeof colorectal carcinomasand their degree of differentiationwhen cytogenetically abnormaltumors were divided into those with only numericalchanges and those also having structural aberrations(Bardi et al., 1993a, 2004). Carcinomascarrying structuralchromosomal rearrangementswere more often poorly differentiated,whereas well- and moderately differentiatedtumorsmore often had only numericalaberrationsor normalkaryotypes. In largebowel adenomas,an associationbetween cytogenetic patternand the tumors' degree of dysplasia, histologic type, and size was found (Bomme et al., 1994, 1996a, 1996b). All villous and tubulovillous adenomas, that is, the adenomas most likely to progressto carcinoma,had structuralchromosomeaberrations.Adenomaswithnumerical changesonly were mildly dysplastic,whereasall but one of the adenomaswith structural rearrangementsshowed eithermoderateor severe dysplasia. Furthermore,polyps with a normalkaryotypehad either mild or moderate,but never severe, dysplasia. Polyps with structuralchromosomal aberrationswere on average larger than polyps with only numericalchanges or those with a normal karyotype.The data strongly indicate that the accumulation of chromosomal changes in adenomas correlates with pathologic features: the more malignancy-like the phenotype, the more complex the karyotype. Presumably,this correlationreflects a causal relationship, with the acquired genetic changes enabling the cells to assume an increasinglyaggressive growth pattern.

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TUMORS OF THE DIGESTIVE TRACT

Cytogenetic Pattern and Prognosis In spite of our much-improvedunderstandingof the cellular and molecularmechanisms underlyingcolorectaltumorinitiationandprogression,little is known aboutthe prognostic impactof particulargenomic aberrationsor aberrationpatterns.In a relativelysmall study 15 years ago, a statisticallysignificantcorrelationbetween tumorkaryotypeand patient survivalwas demonstrated(Bardiet al., 1993a). Patientswith complex tumorkaryotypes had shorter survival than did those whose tumors had no or only few and simple chromosomeanomalies. To assess whetherthe karyotypicpatternprovidesvaluableandindependentinformation about the prognosis of individual patients with colorectal cancer, one decade later we attemptedto evaluate simultaneouslythe prognosticimportanceof all nonrandomcytogenetic featuresin 150 patientswith colorectal cancer,examined at the time of surgery, taking into account also the impact of classical clinicopathologic parameters(Bardi et al., 2004). In additionto tumorgradeand clinical stage, complex structuralaberrations as well as rearrangements of chromosomes8 and 16 were in univariateanalysissignificantly correlatedwith shorteroverall survival (0s).Karyotypiccomplexity, rearrangements of chromosomes8 and 16, andloss of chromosome4 were significantlycorrelatedwith shorter disease-freesurvival(DFS). In multivariateanalysis,in additionto tumorgrade,the type of chromosomeaberrations(structuralornumerical),ploidy, andloss of chromosome18came across as independentprognosticfactors. The most strikingcorrelationobservedbetween a specific chromosomeaberrationand prognosiswas theeffect of loss of chromosome18.Thisloss was, togetherwith tumorgrade, found to be an independentpredictorof short survival in the entire group of patients. loss of chromosome18 was shown to be a strongerindependentpredictorof Furthermore, prognosis than tumorgrade in the subset of patients having cancers of the intermediate stages I1 and 111. Althoughseveral candidatetumorsuppressorgenes on the long arm of chromosome I 8 have been identified, including DCC, DPC4/SMAD4/MADH4, and SMAD2/MADH2, none of them is mutatedin most colorectalcancercases with 18q loss (Woodford-Richens et al., 2001 ;Zhouet al., 2002). In addition,studiesusing microsatellite markersto assess allelic imbalances in colorectal carcinomashave shown that larger chromosomalsegmentswere lost significantlymore frequentlythansmallerones in cases with 18q loss, indicating,as we see it, thatthe crucialevent perhapsis not at the genic butat the genomic level, meaning that in this case, tumorprogressionis facilitatedby global or imbalancesratherthanby single gene mutationsor losses. genomic rearrangements In the subsetof patientswith stage I and I1 carcinomas,none of the clinico-pathologic variablescould independentlypredictpatientsurvival,whereasthe presenceof structural chromosomalaberrationswas the only independentpredictorof poor prognosis (Bardi et al., 2004). In the subsetof patientswith stage tI1 carcinomas,the presenceof structural changesof chromosome8 was a strongerindependentpredictorof prognosisthanwas tumor grade.The correlationof structuralrearrangements of chromosome8 with 0s and DFS in univariateanalysis,togetherwith the emergenceof this chromosomalvariablein multivariate analysis as the strongestpredictorof poor disease outcome in stage 111 patients,was also a remarkablefinding. It is presentlyunknownwhether,let alone how, the colorectal cancer susceptibilitylocus recently identifiedat 8q24 by S N P genotypingof individuals affectedby colorectalcancerand normalcontrols(Zankeet al., 2007), is in any way linked to the developmentof the aggressiveclinical phenotypewe could observein the clinicocytogeneticcorrelationanalyses.

CORRELATION BETWEEN KARYOTYPICAND PHENOTYPIC FEATURES

443

In a CGH studyof 50 colorectalcarcinomaswith and without lymph node metastases, Ghadimiet al. (2003) foundthatgain of 8q23-24 was stronglyassociatedwith lymphnode positivity, and thereforesuggested that gain of this chromosomeregion could be used to predictan increasedmetastaticpotential.In anotherCGHstudyof 67 sporadiccarcinomas (DeAngelis et al., 2001), 8p loss was foundto be anindependentpredictorof poorsurvival, whereasan allelic imbalancestudyof 508 carcinomasshowedthat8ploss was a predictorof dismal outcome in colorectal cancer patients of Astrel-Collerstage B2 or C (Halling et al., 1999). Althoughthe above moleculargenetic data appearto be at odds with one another,suggestingeitheramplificationof an oncogene at 8q or loss of a TSG at 8p as the pathogeneticallyimportantevent, they are both explainedby the cytogeneticfindingof an i(8q), whichindeedis the mostcommonstructuralaberrationof chromosome8 in advanced colorectalcancer (Bardiet al., 1995b). The generationof an i(8q) is thereforeassociated with the developmentof lymph node metastasesin colorectalcancer,but the molecular mechanismswhereby the simultaneousloss of 8p and gain of 8q exert such an influence remainunknown. A correlationbetweenthe occurrenceof structuralrearrangements of chromosome16 in the tumorcells and 0s as well as DFS in colorectalcancerpatientswas for the first time suggestedby Bardiet al. (2004). Becausesuch aberrationshave been foundto be predictors of unfavorableoutcome in other advanced malignancies as well (e.g., hepatocellular malignancyand bladdercancer),they might be generalmarkersof tumoraggressiveness whose prognosticinformationvalue is not restrictedto largebowel cancer.The association of karyotypicloss of chromosome4 with a shorterDFS, foundin the samestudy,agreeswell withpreviousdataby Arribaset al. ( I 999) indicatingthatLOHat severalchromosome4 loci was associatedwith a shorterDFS in colorectalcancerpatients,as well as with morerecent data by Al-Mulla et al. (2006), who suggested that LOH at chromosome4 loci was associatedwith metastaticrecurrenceof early stage disease. Duringthe last decade,severalstudies-most of themusing CGHor LOHapproacheshave provided evidence that allelic imbalanceson several chromosomescorrelatewith prognosisin colorectalcancerpatients(Araganeet al., 2001; De Angelis et al., 2001; Zhou et al., 2002; Knosel et al., 2003; Aust et al., 2004; Diep et al., 2006). The involvementof chromosomeregionspreviouslydetectedby karyotypingalonewas also confirmedin a BAC array-CGHstudy of 121 colorectalcarkinomasby Nakao et al. (2004). Multiple pieces of evidence coming from different genome-wide screening studies thereforeindicate that cytogenetic tumorfeaturesare valuablepredictorsof prognosis in colorectalcancer patients.Researcheffortsshould,in our opinion,now be focused on the cytogenetic,includingmolecularcytogenetic,characterization of phenotypicallyhomogeneous subsets of tumors to define more accurategenomic predictorsfor each distinct phenotypicsubset (topography,histopathology,and clinical stage).

Cytogenetic Pattern and Clinical Management of Colorectal Cancer The majorityof colorectalcancersare not diagnosedin the early stagesof disease because the tumorsoften do not give rise to symptomsor signs untilthey arequite large,sometimes untilthey have alreadymetastasized.In spiteof this,the developmentof diagnosticsystems based on the early genetic characteristicsof colorectallesions standsout as a primegoal. Such knowledge not only might direct our experimental therapeuticfocus towards molecularmechanismsthat have gone awry in the recently transformed,neoplasticcells,

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but also this kind of informationmight potentiallybe made use of in high-riskpopulation screeningprogramsor at regularcheck-upexaminations.Already availablecommercial stooltestsbasedon theuse of geneticmarkersforpresymptomaticdetectionare examplesof how genetic profilingmay be used in a clinical setting (Dong et al., 2001). The appropriatemanagementof individualswith precursorpolyps is of utmost importance; some of these individualswill develop adenomas again, even after endoscopic removal, and a small percentage will go on to have colorectal cancer. The use of appropriatelyselected panels of genetic markersassociatedwith adenomarecurrenceor progressionto carcinomamight pave the way for an individualizedpatient management based on the pathogeneticelements in tumor development.The recent introductionof molecularcytogenetictechniques,especiallythe applicationof FISH probeson interphase cells in histologicalsections,may serveas a geneticdiagnosticsystemto assessthepotential of excised colorectallesions,by detectingchromosomeorgene alterations,forexampleloss of 17p, that seem to be linked to the carcinomatransitionindependentlyof the initiating chromosomalevents. Standardtreatmentfor colorectalcancer includes adjuvantchemotherapyfor patients with lymphnode metastases,butnot forthose withoutmetastaticdisease.However,20%of the latter group eventually die from disease spreading.The identificationof complex karyotypesand structuralrearrangements of specific chromosomesas indicatorsof poor diseaseoutcomealludedto abovecouldassist oncologistsin decidingwhich patientsmight benefitfrom adjuvanttreatmentaftersurgery.Some possibilitiesthatimmediatelypresent themselves,but which, we hastento emphasize,first need to be confirmedin prospective clinico-cytogeneticcorrelationstudiesandthen to be testedout in appropriatetrials,would be the following: colorectalcancerpatientswhose tumorprofilesdifferfrom the high-risk patternsalreadymentionedmay not requireadjuvanttreatmenteven if this would otherwise be recommendedon the basis of standardstaging.Patientswith primarycarcinomashaving rearrangements of chromosome8 and/orloss of chromosome 18, even in the absence of apparentlymph node metastases,should be consideredto be at high metastaticrisk and thereforemay be eligible for chemotherapythat would not be warrantedfor clinically similarpatientswithoutaberrationsof chromosomes8 or 18 in theirtumorkaryotypes.The use of FISHprobesspecificforloci on chromosome18 as well as for8p and8q could provide informationsufficientto performa preliminaryrisk groupingof colorectalcancers.Loss of chromosomeI8 andi(8q) formationcan be detectedeven in interphasenuclei isolatedfrom histologicalsections, whereaswhole chromosomeprobescan be used on metaphasecells wheneverfresh tumormaterialis available.A FISH test as partof the routinelaboratory evaluationof large bowel canceris, in some respects, more reliablethan analogousDNA tests thathave alreadybeen proposedfor a genetic-basedprognosticationsystem,because the cells are examinedindividuallyand not as a DNA mixturefrom normaland malignant cells. It is also much simplerthancompletekaryotypicanalysisof a tumorsample,which requiresconsiderablecytogenetic expertise. Besides, when the independentprognostic value of additionalchromosomeaberrations(such as that of chromosomes4 and 16) is definitelyprovenfor a particularclinical subsetof colorectalcancer,one might also utilize additionalspecific FISH probesto assess prognosismore accuratelythan is possible based on only the standardhistopathologicevaluation. In addition,interindividualgeneticdifferencesarenow being consideredin the development of new drugs, which may soon lead to individualizedtherapiesof patients with colorectalcancer.The ultimategoal is to arriveat therapiesthat are at the same time both rationalandindividualized:rationalbecausethey rely on medicationsdesignedto counteract

PANCREAS

the pathogeneticevents that lie at the heartof colorectalcarcinogenesisand individualized becausethey pay properattentionto the geneticpeculiaritiesof both “individuals” locked in combatin cancerdiseases,the geneticmakeup of the tumorcells as well as thatof the host, the patient.

PANCREAS Karyotypic abnormalitiesof altogether 126 pancreaticadenocarcinomas have been reportedin six studies (Johanssonet al., 1992; Bardi et al., 1993d; Griffinet al., 1994, 1995;Gorunovaet al., 1998;Kowalskiet al., 2007). The maincytogeneticfeaturesrevealed by the karyotypingof these carcinomasare the high level of complexityand the extensive intratumorheterogeneitythey display. One reason behind this complexity could be that samplesforcytogeneticanalysisareonly madeavailableat very latediseasestages.The lack of benign precursorlesions that can be subjected to cytogenetic study diminishes the possibility of distinguishingprimaryfrom secondaryaberrationsin the massively altered genomicpictureusually observedin carcinomasof the pancreas.The same holds truealso for the possibility of findinggenotypic-phenotypiccorrelationsin pancreaticcancer;most tumorsare examinedat too late stages of disease for this to be feasible. The availablekaryotypicinformationindicatesthatall chromosomeshavebeen involved in unbalancedstructuralaberrationsas well as gains and losses in pancreaticcancer.Their frequencyof involvementdiffersconsiderablyamongthe variousseries, however.Twentytwo carcinomasof the exocrinepancreaswith tumorstemlinesrangingfrom hypodiploidto hypotetraploidweredescribedby Johanssonet al. (1992) andBardiet al. (1993a).The most common numericalaberrationswere, in orderof falling frequency,- 18, -Y, + 20, 7, I 1, and - 12. The karyotypicimbalancesbroughtabout by structuralrearrangements frequentlyaffectedchromosomes1,8,and 17. Thebreakpointsof the structuralaberrations 14pll,15q10-1I,and17ql1 (Bardi clusteredtobandslp32,lql0,6q21,7p22,8p21,8qll, et al., l993d). Abnormalkaryotypeswere more often found in poorly differentiatedand anaplasticcarcinomasthan in mode.rately and well differentiatedtumors.Patientswhose tumorscontainedcomplex numericaland structuralaberrationshad significantlyshorter survivalthandid those with simple tumorkaryotypes(Johanssonet al., 1994). Griffinet al. (1994, 1995) describedanother44 pancreaticcarcinomaswith karyotypicabnormalities. Themostcommonnumericalaberrationswere gainsof chromosomes20 and7 andlosses of chromosomes18, 13, 12, 17, and 6. Two hundred andnine breakpointswere identifiedas involved in structuralrearrangements affecting,in orderof decreasingfrequency,chromosome arms Ip, 6q, 7q, 17p. Iq, 3p, 1 Ip, and 19q. Extensive intratumorcytogenetic heterogeneity(ICH) and a high level of karyotypiccomplexity were the most impressive cytogeneticfeaturesdescribedby Gorunovaet al. (1 995, 1998) in a seriesof 25 karyotypically abnormalpancreaticcarcinomas.Nineteen of the examinedtumorseach displayed from 2 to 58 clones. Karyotypicallydocumentedclonal evolution in the form of related clones was detectedin I6 tumors,whereasseeminglyunrelatedclones werepresentin nine anda total tumors.Altogether,608 breakpointswere involvedin structuralrearrangements, of 19 recurrentunbalanced structuralchanges were identified. The main karyotypic imbalanceswere whole-copy losses of chromosomes18,Y,and 21, gains of chromosomes 7,2, and20, partialor whole-armlosses of 1 p, 3p, 6q,8p, 9p, 15q, 17p. 18q, 19p,and 2Op, and partialor whole-armgains of lq, 3q, 5p, 6p, 7q, 8q, 1 lq, 12p, 17q, 19q, and 20q. To explorethemechanismsof ICH,Haradaetal. (2002) investigatedinterglandular variationin

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TUMORS OF THE DIGESTIVE TRACT

20 primaryinvasiveductaladenocarcinomasof the pancreasby CGHanalysis.The profiles displayeda wide varietyof differencesbetween multipleadjacentneoplasticglandswithin the same tumorin all cases, that is, interglandularcytogeneticheterogeneityas measured also by CGHwas pronouncedin pancreaticcancer.Geneticchangesdetectedin all regions of a tumorwere classifiedas “region-independent” alterations,whereaschangesseen in at and resultingin ICH. least one but not all regions were designatedas “region-dependent” The degreeof ICH,which was quantifiedas the ratiobetweenthesetwo typesof alterations, correlatedclosely with the DNA index, andthe authorsthereforesuggestedthatDNA index might be a surrogatemarkerfor ICH. The resultswere interpretedto indicatethat tumor progression,ICH, and DNA aneuploidyresultfrom the successive appearanceof regiondependentalterationsattributableto chromosomalinstabilityin tumorcells. Based on their findings, the authors supported the concept of individualcell heterogeneityin pancreatic cancer. Clonal karyotypicabnormalitiesin another36 primary pancreaticcarcinomasfrom patientswho had undergonea Whippleresectionwith curativeintentwere recentlyreported by Kowalskiet al. (2007). Most of the tumorswere diploidor triploid.Most commonlylost were chromosomes18, 17,6, 21, 22, Y,and 4. Chromosome20 was the most frequently gained.Structuralabnormalitieswere also common,resultingin partialchromosomalgains and losses, and with a mediannumberof 7 imbalancespercase (range, 1-1 5). Cytogenetic evidenceof gene amplification,double-minutechromosomesand homogeneouslystaining regions, was seen in 16 carcinomas. In spiteof the differentcytogeneticfeatureshighlightedin variousstudies,the poolingof all presently available karyotypic data on pancreatic adenocarcinomasallows us to distinguish some very interesting features (Fig. 13.7): monosomy 18, described as a common change in all series, is the most frequentchromosomeaberration(60%of all cases). Severalotherrecurrentaneusomiesfollow but theirfrequencyis clearly lower than thatof-l8.Thus,-l7,-21,-6,-Y, +7,-4,-X, +20,-12,-22,and-9areallseenin 25-38% of the cases. Interestingly,none of recurrentbreakpointsseen in the plethoraof structuralrearrangements identifiedin the six series reacha frequencyhigherthan 13%in

40

20

B

0

!l

”0 -20

zd -40 -60

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 X Y

Chromosome

FIGURE 13.7 Distribution of numerical chromosome aberrations in 126 pancreatic adenocarcinomas with clonal chromosome aberrations.

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themeta-analysis.Chromosomebands13q10,19q13,lq10,8q10,14q10,17pll,and 17q10 arethe mostcommonsites of breakpoints(8- 13%).Mostof themarecommonlyinvolvedin othergastrointestinalmalignanciesas well and,with the exceptionof 19q 13, they areall at or close to the centromeres. Additionalstudies, preferablyutilizingmultipleinvestigativetechnologies,are clearly needed to shed more light on the genetic eventsunderlyingpancreaticcancerdevelopment andprogression.If one is able to integrateall availablemethodologicaltools atthegenomic, transcriptional,and proteomic level, a more comprehensiveassessment of the overall genomic pictureof these tumorscan surely be arrivedat than is possible on the basis of karyotypingalone.

LIVER AND BlLlARY TRACT None of the various types of primary liver tumor have been extensively examined cytogenetically;the available cytogenetic informationis restrictedto only I53 cases (Mitelmanet al., 2008). Regardinghepatocellular carcinoma, the most common type of liver cancer and the fourth leading cause of cancer death worldwide, our cytogenetic knowledgeis based on only 22 cases with abnormalkaryotypes(Simonet al., 1990; Bar& et al., 1992b, 1998; Werneret al., 1993; Chen et al., 1996; Lowichiket al., 1996; Hany et al., 1997; Paradaet al., 1998; Wong et al., 1999). The characteristicfeaturesthat are apparentshould thereforebe viewed with some caution. The combined data show that hepatocellularcarcinomasare generally highly complex cytogenetically with multiple numericaland structuralchromosomeaberrations.Although none of the observedchromosome changes appearsto be specific for this type of tumors,some abnormalitiesare frequent(20-35%) and characteristicsuch as i(8)(q10), deletions of the short arm of chromosomeI , trisomy7, andmonosomyforchromosomes5,8,13,21, and22 (Fig. 13.8). Many CGH studies (Wong et al., 1999; Kitay-Cohenet al., 2001; Nishida et al., 2003: Hashimotoet al., 2004; Patilet al., 2005) havenot only confirmedthe imbalancesseen by Gbandinganalysis, but also identifiedlosses and gains of several additionalchromosomal

2

3 4

5

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8 9 10 11 12 13 14 15 16 17 18 20 21 22 X Y Chromosome

FIGURE 13.8 Distribution of numerical chromosome aberrationsin 22 hepatocellular carcinomas with clonal chromosome aberrations.

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regions as nonrandomgenomic events in hepatocellularcarcinomas.Althoughthe distributionof aberrantchromosomalarmsdiffersamongtumorsandalsoamongdifferentseries, a CGH meta-analysisof 785 human hepatocellularcarcinomas and 30 premalignant dysplasticnodules(Moinzadehet al.. 2005) showed thatthe most prominentamplifications of genomic materialtook place in I q (57. I %), 8q (46.6%),6p (22.3%),and 17q (22.2%), whereaslosses weremost prevalentin 8p (38%), 16q(35.9%).4q (34.3%),17p(32.1%), and 13q (26.2%). In poorly differentiatedtumors, 13q and 4q were significantlyunderrepresented. Moreover,gains of 1q were positively correlatedwith the occurrenceof all other high frequencyalterations.In premalignantdysplasticnodules,amplificationswere most frequentlypresentin l q and 8q, whereasdeletionsoccurredin 8p, 17p, 5p, 13q, 14q, and 16q. The authorsconcluded that etiology and dedifferentiationcorrelatewith specific genomic alterations in human hepatocellularcancer. That accumulationof genomic imbalances,includingthe acquisitionof specificchanges such as gain of 8q, is associated with tumor progression,was also found by Patil et al. (2005) in an aCGH study. The identificationof other aberrations,such as loss of lp, not only in well-differentiated hepatocellularcarcinomasbut also in dysplastic and cirrhotichepatic nodules, suggests thatchromosomalinstabilitymay occurat an earlystageduringhepatocarcinogenesis, well before the emergenceof a malignantphenotype(Nishidaet al., 2003). Moleculargeneticstudieshaverevealeda high numberof alteredgenes in hepatocellular cancer,suggestingthe existence of at least fourdifferentpathogeneticpathways:the TP53 pathwayinvolved in responseto DNA damage,the RES1 pathwayinvolvedin controlof the cell cycle, the TGFB pathway involved in growth inhibition, and the WNT pathway involved in cell-cell adhesionand signal transduction(Saffroy et al., 2006). These main pathwaysmay be alternativeto one another,butthey couldalso possibly be complementary. Hirotoet al. (2007) recentlystudied87 hepatocellularcarcinomascombininggenome-scale chromosomecopy numberalterationprofiles and examinationof the mutationalstatusof TP53 and CTNNBl. The resultsled them to suggest that hepatocellularcancerconsists of several genetically homogeneoussubclasses,each of which harborscharacteristicgenetic alterationsand even pathognomonicchromosomal amplifications,for example MYCinduced tumors, 6p/l q-amplifiedtumors, and 17q-amplifiedtumors.The applicationof global genomic and proteomicmethodsto analyze largeand clinically well characterized tumor series should be able to test the proposed hypotheses regardingthe cause and functionalsignificanceof genomic alterationsin human hepatocellularcancer. The mostcommonlivertumorin childhoodis hepatoblastornu.At thepresenttime,about 100 cases with abnormalkaryotypesare known (Mitelmanet al., 2008). The firstdatacame fromsmall studies(Fletcheret al., 1991;Rodriguezet al., 1991;SoukupandLampkin,1991; Bardiet al., 1991b, 1992a;Schneideret al., 1997; Sainatiet al., 1998; Paradaet al., 2000) presentingthe karyotypesof single or up to six cases. Only the recentstudyby Tomlinsonet al. (2005) presentedtheresultsof a largeseriescomprising1 1 1 hepatoblastomaskaryotyped over a period of 12 years, with abnormalkaryotypesbeing identified in almost half the tumors.Numericalchangeswereseen in 36%of thetotalnumberof caseswhereasonly 18% displayedstructuralrearrangements, which were mostly unbalancedandresultingin gain of I q. Among the numericalchanges,the most frequentwere trisomiesfor chromosomes2,8, and 20. Losses of whole chromosomeswere less common than gains. If we mergethe dataof Tomlinsonet al. (2005) with the earlierfindingsby othergroups, we see thatthe few structuralchromosomerearrangements foundin hepatoblastomas all are unbalancedandmostly involve chromosomes1,4, and8 at 1q 12, lq 10,4q33-34, and 8qlO. Themostcommonnumericalabnormalityis trisomy20 (52%),followed by trisomy2 (40%)

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with

and trisomy8 (34%)(Fig. 13.9). None of thechromosomelosses reachesa frequencyhigher than 7% in the total numberof reported cases. Also CGH data indicate that gains of chromosomalmaterialare characteristicimbalancesin hepatoblastomas,as they occur almost sevenfold more frequentlythan losses (Weberet al., 2000). Cytogeneticevidence (Sainatiet al., 1998; Paradaet al., 2000) suggests that trisomy 20 occurs duringclonal evolution as a progression-relatedchange rather than as an early event. As gain of chromosome2 is alsocommonlyfoundin embryonalrhabdomyosarcoma, anotherpediatric neoplasmassociatedwith Beckwith-Wiedemannsyndrome,this aberrationmight constitute a critical step in the developmentof embryonaltumors.Highly amplifiedsequences havebeen identifiedin somecases mappingto 2q24,8q I 1.2-13, and8q11.2-2 I .3 (Weberet al., 2000), but the relevant targetgenes of these changes have not yet been found. Of particularclinical interest was the correlationanalysis, performedby the same group, between specific genomic alterationsand the disease outcome for 34 hepatoblastoma patients;they found thatgains of 8q and chromosome20 were genetic predictorsof poor clinical outcome in this disease. Only isolated reportshave describedchromosomalaberrationsin other types of liver tumors.Mascarelloand Krous( 1992) were the first to describethe translocationt( 1 I :19) (q 13;q13) in mesenchymalliver hamartoma.Laterreportshave confirmedthe presenceof this translocationin additionalcases (Bove et al., 1998; Rakhejaet al., 2004; Sharif et al., 2006). Very recently, the cloning and DNA sequence analysis of the translocation breakpointswas reported(Rajaramet al., 2007) in an undifferentiatedembryonalsarcoma arising in a mesenchymal hamartomaof the liver carryingan identical t( 11;19). The breakpointat 1 I q 13 occurs in the MALATI gene, also known as ALPHA. MALATl is also rearrangedin renal tumorscarryingthe t(6;l l)(p21;q13) translocation(Chapter14), and noncodingMALATl transcriptsareoverexpressedin a numberof humancarcinomas.The breakpointat 19q13.4 occursat a locus referredto as MHLBI. Althoughthe MHLBI locus does not containanyknowngene, severalhumanexpressedsequencetags (EST)mapto the region, a subset of which show homology to the nuclearRNA export factor (NXF) gene family, and the region is conserved in many mammalianspecies.

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The existing cytogenetic informationon biliary tracttumorsis restrictedto 24 cases, nearly all of them gallbladder adenocarcinoma. In the first cytogeneticallyexamined gallbladdercarcinomas(Hecht et al., 1983; Bardiet al., 1994), the most prominentfeature was the highly complex, abnormalkaryotypicpattern,with cytogeneticevidence of gene amplification,aneuploidtumorstemlines,and severalrecurrentimbalances.CombiningGbandingand CGHdataon 14 carcinomas,Rijkenet al. ( 1999)foundthat 1 1 chromosomal arms were gained entirelyor in part,whereaslosses occurredfromor of nine chromosome armsin at leastfourtumorseach;the lost chromosomalregionswere,in decreasingorderof frequency,18q,6q, lop, 8p, 12q, 17p,7q, 12p,and22q, whereasthe most frequentlygained regionswere 8q, 20q, 12p, 17q, Xp, 2q, 6p, 7p. 1lq, 13q,and 19s.Onthe basisof thesedata, the authorssuggestedthatcarcinomasof the biliarytractand pancreassharea numberof genetic changes. Extensive intratumorheterogeneity,in the form of unrelatedclones and altogether 25 1 breakpointsinvolved in structuralaberrationsin seven karyotypically abnormaltumors, was reportedby Gorunovaet al. (1999). The aberrationsde1(3)(p13), i(5)(p10), de1(6)(q13),de1(9)(p13), del( 16)(q22), del(17)(pl I), i(17)(qlo), del(l9)(p13), and i(21)(q lo), knownto occur in othergastrointestinalcarcinomasas well, appearedto be recurrentalso in gallbladdercarcinomasin that study.

STOMACH Clonalchromosomeabnormalitieshavebeen reportedin altogether1 33 gastric carcinomas (Mitelmanet al., 2008). Except for four undifferentiatedcarcinomas,all were adenocarcinomas,the mostcommonstomachcancersby far.Some werestudiedascancerouseffusions and severalcases were incompletelykaryotyped.Althoughthe evolving pictureof gastric cancer karyotypes is still incomplete, several characteristiccytogenetic features are discernible,most of them common to malignanciesof the digestivetract in general. Almost all structuralchromosomeaberrationsreportedso farin gastriccarcinomasare unbalanced,with the most common(Fig. 13.10)being i(8)(q lo), foundin around10%of all 12

10

a v)

f

{ 6

2 4

2

0 \Q

Chromosome bands I p36 Yq ~

FIGURE 13.10 Distributionof chromosomalbreakpointsinvolved in structuralrearrangements in 129 adenmarcinomas of the stomachwith clonal chromosomeaberrations.

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cases, followed by deletionof 3p21 in about7%,and rearrangements of 7q22, i(17)(q10), i(13)(q10), deletion of lp22, and i(5)(p10), all of which are found in roughly5%. It is worth emphasizingthat all the most frequent numericalchromosomalevents in gastric adenocarcinomasrepresentimbalancesrepeatedly described also in colorectal cancer: trisomy 8 (22%). trisomy 20 (20%), and trisomies for chromosomes7 and 13 (10%). Monosomies appearto be more frequentthan gains but this may be a result of incomplete karyotypicdescriptionof many complex karyotypes.In any case, the most commonlosses seem to be monosomy 18, loss of the Y,andmonosomiesfor chromosomes 22,21,9, 17, 14, 16, and X, all reportedin 2 6 2 8 % of the cases. This overall aberrationpatternlargely correspondsto the gain-and-losspicture that emergedalreadyfromearly,smallerstudies(Ferti-Passantonopoulou et al., 1987; Misawa et al., 1990; Rodriguezet al., 1990;Xia et al., 1992;Rao et al., 1993; Semca et al., 1993). Morerecently,cytogeneticandFISHstudieshavehighlightedthe high incidenceof totalor partialgain of chromosome8 materialin gastriccarcinomas.Xiao et al. (1999) suggested thattrisomyfor chromosomes8 and 9 as well as deletionof 7q32-qterareimportantin the initiationand progressionof gastriccancer.Panani et al. (2004), using an alpha-satellite DNA probeforchromosome8, foundtrisomyfor thischromosomein up to 62%of the cases without apparentpreferencefor any histopathologicsubtypeof tumors. Calcagnoet al. (2006) confirmed that chromosome 8 aneuploidy occurs independentlyof the tumor histological type but observed differencesin the amplificationand expression status of MYC between diffuse and intestinal-typegastriccancer. Kitayamaet al. (2003) investigated 51 formalin-fixedand paraffin-embeddedtissue samples of gastric carcinomaswith a panel of 18 centromericprobes for chromosomes 1 4 , 6-12, 15-18,20, X and Y as well as locus specific probesfor MYC (8q24) and TP53 ( I7pI 3). Aberrations of chromosomes1,8,17,20, andXwerefrequentregardlessof histology althoughmucocellulartypetumorsappearedto havemorestableaneusomiesthandidtubular type carcinomas.A difference in the clinical outcome of patients whose tumors had aneusomies for chromosomes 3, 10, 11, 12, 17, and Y was suggested; however, the investigatorsneitherscreenedall chromosomesnorperformedmultivariateanalysisto assess whetherthe proposedchromosomalpredictorscould be independentprognosticfactors.The prognosticsignificanceof genomic alterationsin 74 patientswith gastriccancer was also assessedby Suzukiet al.(2003) in a comparativestudyof pairednormalandtumortissueDNA fingerprints.In a multivariateCox analysis,they showed thatthe fractionof genomedamage was a prognosticas well as a stage indicatorin gastriccancer. Survivalwas significantly diminishedfor patientswhose tumorsshowed a genomicdamagefractionhigherthan the cutoffset at0.22. Thedegreeof genomicdamageestimatedby arbitrarily primedpolymerase chain reaction(AP-PCR)was the only independentfactorpredictingsurvival. Weiss et al. (2003), in a correlationstudy of tumor genomic profiles and clinicopathologicfeaturesof 35 patientswith gastriccarcinoma,found that chromosomalcopy numberchangespredictedlymphnode statusand survival.Using a genome-widescanning arraywith 2275 BAC and PI clones giving an averageresolutionof 1.4 Mb across the genome, they showed that the group of gastriccancers with the lowest mean numberof chromosomalevents (gains, losses, and amplifications)per case had significantlybetter survivaland lower risk of lymph node metastasis. Ottiniet al. (2006) showedthatmicrosatelliteandchromosomalinstabilitypathwaysas well as CpG islands methylatorphenotype(CIMP)play a role in gastriccarcinogenesis. Although the MIS, CIN, and CIMP phenotypesare in general separate,some degree of overlap has been suggested in gastric cancer, as seems to be the case also for other malignanciesof the digestive tract(Ottiniet al., 2006).

6 2

TUMORS OF THE DIGESTIVE TRACT

1

2

3

4

5

6

7

9

10

12 14 15 17 19 20 21 22 X

Y

Chromosome

FIGURE13.11 Distributionof numericalchromosomeaberrationsin 22 GISTof the stomachwith clonal chromosome aberrations.

Very little is known about gastric tumors other than carcinomas.There is nothing indicatingthat leiomyosarcomasof the stomachdiffer in their karyotypiccharacteristics from malignantsmoothmuscle tumorsof otherlocales; the cytogeneticsof these tumorsis discussedin Chapters16 and23. Similarly,gastriclymphomassuchas extranodalmarginal zone B-cell lymphomasare discussedin Chapter10. Altogether22 gastrointestinal stromal tumors (GIST)of the stomachwith karyotyped chromosomeaberrationshave been published. Deletion of l p l 1 is the only recurrent, structuralaberration,identifiedin two tumors. However,a remarkablyhigh frequencyof some numericalchromosomechanges(Fig. 13.1 1) has been demonstrated,with monosomy 14 found in 72% of cytogeneticallyexaminedGISTand monosomy 22 in 45%. DebiecRychteret al. (2001), in a molecularcytogeneticstudyof 35 tumorsusing 2 I YAC clones specific for I4qll-24, foundtotalorpartialloss of 1% materialin 81%of thecases. Distinct critical deletion regions were identified at 14q23-24 and at 14ql1-12, but the genes involved remainunknown. Activating mutations of the proto-oncogene KIT, which encodes a growth factor transmembranereceptor,and PDGFRA (which encodes platelet-derivedgrowth factor receptoralpha),both residingnext to each otheron the long arm of chromosome4, have been shown to be major players in GIST pathogenesis (Hirota et al., 1998; Heinrich et al., 2002b).KITandprobablyalso PDGFRA arevery importantfor the interstitialcells of Cajal(ICC),cells thatarefoundalongthe entirelengthof the digestivetractandwhichhave an importantfunctionin the coordinationof peristalsis.ICC stronglyexpressKITprotein and loss of KIT results in loss of ICC. KIT or PDGFRA mutationsare consideredto be initiatingevents that give rise to GIST (Heinrichet al., 2002b; Rubin et al., 2007). Most GIST have an activatingmutation in KIT or PDGFRA and respond to treatmentwith imatinibmesylate,a smalltyrosinekinaseinhibitorthatblocksdownstreamsignalingof the mutatedkinase.The introductionof this drughasdramaticallyimprovedsurvivalin patients with unresectableor metastaticGIST; however, approximately15%of patientsdo not respondto imatinib,and manyothersprogressafteran initialperiodof responseor disease stabilization(Heinrichet al., 2002a; Boyar and Taub,2007).

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SMALL INTESTINE From this relatively neoplasia-free organ, only 33 tumors with clonal chromosome aberrationshave been reported(Mitelman et al., 2008). The very limited cytogenetic informationconsists of case reportsor series of only few cases fromeach of the following mesenchymaltumors:gastrointestinalstromaltumors,leiomyosarcomas,clear-cellsarcomas,leiomyomas,as well as a few extranodalmarginalzone B-cell lymphomas,carcinoids, and a single case of adenocarcinoma. The data are much too few to attemptto assess independentlythe cytogenetic characteristicsof thesedifferentdiagnosticentitiesthatshareonly the sameanatomicallocation. The readeris referredto otherchaptersfor a generalsurvey of the karyotypicfeaturesof mesenchymaltumorsand lymphomas.

SUMMARY Colorectaladenomasare in generalkaryotypicallymuchmore simplethantheirmalignant counterparts,butno single chromosomeaberrationcan distinguishbenign from malignant lesions of the large intestinewith certainty.Gain of chromosome7 and deletion of lp36 appearto be earlygeneticevents in colorectaltumorigenesis.Theprogressionof low-grade to high-gradeadenomasandthen to colorectalcarcinomas,followed by metastasisto lymph nodes and distal organs, is accompaniedby the acquisitionof additionalchromosomal changes,the most commonof which aregainsof chromosomes20 and 13, loss of 17p,gain of 17q,monosomy 18, gainof 8q, andlosses of 8p and4p. Metastaticlesions generallyshow less clonal heterogeneitythan do the primarytumors,but instead increasedkaryotypic complexity of individual clones. Homing of metastasizing colorectal tumor cells to particularorgansseems to occur via differentpatternsof genomic alterations.The overall cytogeneticpattern,the instabilitystatusas well as the cytogenetic predictorsof clinical outcomediffer dependingon the anatomicalsite of largebowel tumors.Loss of chromosome 18 and structuralrearrangements of chromosome8, leadingto loss of 8p and gain of 8q, are predictorsof high metastaticrisk, even in the absenceof lymph node metastases. Informationcan thereforebe derivedfrom the karyotypeaboutthe prognosisof colorectal cancerpatientsand,hence,couldprovideclues as to how patientswith earlyor intermediate stage tumorsshould best be treated. High-level karyotypiccomplexity and extensive intratumorheterogeneityare the most prominentcytogeneticfeaturesof pancreaticadenocarcinomas.Monosomy 18 is the most frequentaberrationpresentin 60%of all cases. Otherfrequentaneusomiesare -17, -21, -6, -Y, + 7, -4, -X, 20, - 12, -22, and -9. Recurrentbreakpointsmostly are in or near the centromeres:13q10, 19q13, Iq10, 8q10, 14q10, 1 7 ~ 1 1and , 17q10. Karyotypic complexity is significantlyassociatedwith shorterpatientsurvival. Severalabnormalities,includingi(8)(q10),deletionsof lp, trisomy7, andmonosomyfor chromosomes5 , 8 , 13,21, and 22, are frequentin hepatocellularcarcinomas.Preliminary data indicate that etiology and tumor differentiationcorrelate with specific genomic alterations.Chromosomalalterationscan be found also in dysplasticand cirrhotichepatic nodules. Recurrenttrisomies,especially 20, 2, and + 8, occurfrequentlyin hepatoblastomas. In contrast,monosomiesareless commonand the same seems to be the case also for structuralaberrations.Structuralrearrangements,which always are unbalanced,mostly

+

+

+

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affect chromosomes1,4, and 8 at bands lq12, lq10,4q33-34, and 8q10. Gainsof 8q and chromosome20 may be genetic predictorsof poor clinical outcome in hepatoblastoma patients. A specific balancedtranslocation,t( 11;19)(q13;ql3), characterizesliver hamartomas. The gene MALATl (ALPHA) is the target in 1 lq13, whereas the breakpointin 19q13.4 occurs at a locus referredto as MHLBI. Karyotypiccomplexity and intratumorheterogeneityas well as several genomic imbalancesare the main cytogeneticfeaturesof gallbladdercarcinomas,a type of tumorthat from the cytogenetic point of view seems to have many similaritieswith pancreatic carcinomas. Almost all structuralaberrationsin gastricadenocarcinomasare unbalanced:the most common are i(8)(qIO),deletion of 3 ~ 2 2rearrangements , of 7q22, i(17)(qlO), i(13)(qIO), deletionof lp22, and i(5)(p10).The numericalchromosomeaberrationslargelycorrespond to those knownfromcolorectalcancer:tnsomy for chromsomes8,20,7, and 13 andloss of chromosomes18, Y,22,21,9,17,14,16, andX. A remarkablyhighfrequencyof monosomy 14 (72%) and monosomy 22 (45%)is observedin gastrointestinalstromaltumorsof the stomach.Currentlymoreimportanttherapeuticallythanthe cytogeneticaberrationsseen in these tumors is the consistent Occurrenceof submicroscopicmutationsof KIT andor PDGFRA;because of these pathogeneticalterations,tyrosine kinase inhibitortreatment with imatinibmesylate has proven highly effective for GIST patients.

ACKNOWLEDGMENT Financialsupportfrom the NorwegianCancerSociety is gratefullyacknowledged.

REFERENCES Alcock HE, Stephenson TJ, Roy& JA, Hammond DW (2003): Analysis of colorectal tumor progression by microdissection and comparativegenomic hybridization.Genes Chromosomes Cancer 37:369-380. Al-Mulla F. Keith WN, Pickford IR, Going JJ,BirnieGD (1999):Comparativegenomic hybridisation analysis of primarycolorectalcarcinomasandtheirsynchronousmetastases.Genes Chromosomes Cancer 24:30&3 14. Al-Mulla F, Alfadhli S, Al-Hakim AH, Going JJ, Bitar MS (2006): Metastaticrecurrenceof earlystagecolorectalcanceris linkedto loss of heterozygosityon chromosomes4 and 14q.J Clin Pathol 59:624-630. AraganeH, SakamuraC, NakanishiM, YasuokaR, FujitaY,TanguchiH, HagiwaraA, YamagushiT, Abe T,lnazawaJ, YamagishiH (2001): Chromosomalaberrationsin colorectal cancersand liver metastases analyzed by comparativegenomic hybridization.Znt J Cancer 94:623-629. Arribas R, Ribas M, Risques RA, MasramonL,TortolaS, MarcuelloE, Aiza G, Mi16 R,Capelli G, PeinadoMA ( I 999): Prospectiveassessmentof allelic losses at 4p 14-1 6 in colorectalcancer:Two mutationalpatternsand a locus associated with poorer survival. Clin Cancer Res 534543459. Aust DE.MudersM, KohlerA, SchmidtM, Diebold J, MullerC, Lohrs U, WaldmanFM, BarettonGB (2004): Prognosticrelevanceof 20q I3 gainsin sporadiccolorectalcancers:a FISH analysis.Scand J Gastroenterol39:766-772. BardiG, JohanssonB, PandisN, Heim S , MandahlN,Andren-Sandberg €Gigerstrand I, MitelmanF (1991a): Trisomy 7 in colorectal adenocarcinomas.Genes Chromosomes Cancer 3: 149-1 52.

REFERENCES

455

BardiG, JohanssonB, PandisN, Bkkissy AN, KullendorffC-M. HagerstrandI, Heim S (1 991 b): i(8q) as the primarystructuralchromosomeabnormalityin a hepatoblastoma.Cancer Genet Cytogenet 5 1 :28 1-283. BardiG, JohanssonB, PandisN, Heim S, MandahlN, Bkkissy A, HagerstrandI. Mitelman F (1992a): Trisomy2 as the sole chromosomalabnormalityin a hepatoblastoma.Genes Chromosomes Cancer 4:78-80. BardiG, JohanssonB, PandisN, Heim S, MandahlN, Andren-SandbergA Hagerstrand1, MitelmanF (1992b): Cytogenetic findings in three primaryhepatocellularcarcinomas.Cancer Genet Cytogenet 58:191-195. BardiG, JohanssonB, PandisN, Bak-JensenE, OmdalC, Heim S, MandahlN, Andrimsandberg MitelmanF ( 1993a):Cytogenetic aberrationsin colorectaladenocarcinomasand theircorrelation to clinicopathologicfeatures. Cancer 7 1 :306-3 14. Bard G,JohanssonB. Pandis N, MandahlN. Bak-JensenE, LindstromC, FrederiksenH, AndrenSanberg Mitelman F, Heim S (l993b): Cytogenetic analysis of 52 colorectal carcinomasNonrandom aberration pattern and correlation with pathologic parameters. Int J Cancer 55:422-428. BardiG, PandisN, FengerC, Kronborg0, Bomme L, Heim S ( 1993~):Deletion of lp36 as a primary chromosomal aberrationin intestinaltumorigenesis. Cancer Res 53: 1895- 1898. BardiG, JohanssonB, PandisN, MandahlN, Bak-JensenE, Andrkn-Sanberg Mitelman F, Heim S (1993d): Karyotypicabnormalitiesin tumorsof the pancreas. Br J Cancer 67:1106-1 I 12. Bardi G,GorunovaL, Limon J, JohanssonB, Pandis N, MandahlN, Nedoszytko B, Bak-JensenE, Andrkn-SandbergA, Rys J, NiezabitowskiA, MitelmanF, Heim S (1 994): Cytogeneticfindingsin three carcinomasof the gallbladder.Cancer Genet Cytogenet 76:15- 18. Bardi G,Pandis N, Heim S (1995a): Trisomy 7 as the sole cytogenetic aberrationin the epithelial component of a colonic adenoma. Cancer Genet Cytogenet 8292-84. BardiG , SukhikhT, PandisN, FengerC, Kronborg0,Heim S (1995b): Karyotypiccharacterizationof colorectal adenocarcinomas.Genes Chromosomes Cancer 12:97-109. Bardi G,ParadaLA, Bomme L, Pandis N, Willen R, JohanssonB, Jepsson B, Beroukas K, Heim S, Mitelman F ( 1997a): Cytogeneticcomparisonsof synchronouscarcinomasandpolyps in patients with colorectal cancer. Br J Cancer 76:765-769. BardiG.ParadaLA, Bomme L, PandisN, JohanssonB, Willen R, FengerC, Kronborg0,MitelmanF, Heim S (1997b): Cytogenetic findings in metastases from colorectal cancer. lnt J Cancer L72:604-607. BardiG, Rizou H,MichailakisE, Dietrich C, PandisN, Heim S (1 998): Cytogeneticfindingsin three primaryhepatocellularcarcinomas.Cancer Genet Cytogenet 104:165-1 66. Bardi G, Fenger C. Johansson B, Mitelman F, Heim S (2004): Tumor karyotype predicts clinical outcome in colorectal cancer patients. J Clin Oncol22:2623-2634. Bedenne L, FaivreJMC, BardF, CauvinJM, Hillon P (1992): Adenoma-carcinomasequence or ‘de novo’ carcinogenesis? A study of adenomatousremnantsin a population-basedseries of large bowel cancers. Cancer 69883-888. Bomme L, BardiG, PandisN, FengerC, Kronborg0,Heim S ( I 994): Clonal karyotypicabnormalities in colorectal adenomas: clues to the early genetic events in the adenoma-carcinomasequence. Genes Chromosomm Cancer 10:190-1 96. Bomme L, BardiG, FengerC, Kronborg0,PandisN, Heim S ( 1996a):Chromosomeabnormalitiesin colorectal adenomas: two cytogenetic subgroupscharacterizedby deletion of Ip and numerical aberrations.Hum Pathal27:I 192-1 197. Bomme L, Bardi G,Pandis N, Fenger C, Kronborg0, Heim S (1996b): Cytogenetic analysis of colorectal adenomas:karyotypiccomparisonsof synchronoustumors. Cancer Genet Cytogenet 106:66-7 I.

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BommeL, HeimS, BardiG. FengerC, Kronborg0, BriiggerA, LotheR (1 998):Allelic imbalanceand cytogeneticdeletionof 1p in colorectaladenomas:a targetregion identifiedbetween DI S 199 and DIS234. Genes Chromosomes Cancer 21: 185- 194. Bomme L, LotheR, BardiG,FengerC, Kronborg0,Heim S (2001): Assessmentsof clonalcomposition of colorectaladenomasby FISHanalysisof chromosomes1,7,13,and20. Inf J Cancer 9 2 s 16-823. Bove KE, Blough RI,SoukupS ( 1 998): Thirdreportof t( 19q)(13.4) in mesenchymalhamartomaof liver with commentson link to embryonalsarcoma. Pediatr Dev Pathol 1:438-442. BoyarMS, TaubRN (2007): New strategiesfortreatingGISTwhen imatinibfails. Cancer Invest 2 5 5 328-335. BrabletzT, JungA, SpadernaS, HlubekF,KirchnerT (2005): Opinion:migratingcancerstemcellsan integratedconcept of malignanttumourprogression.Nut Rev Cancer 5744-749. BriiderleinS, van derBosch K,Schlag P, SchwabM (1990): Cytogeneticsand DNA amplificationin colorectalcancers.Genes Chromosomes Cancer 2:63-70. Bufill JA (1990): Colorectalcancer: evidence for distinct geneticcategoriesbased on proximalor distaltumorlocation. Ann Intern Med 1133779-788. CalcagnoDQ,Leal MF, SeabraAD, KhayatAS, Chen ES, DemachkiS, AssumEiio PP, FariaMH, RabenhorstSH, FerreiraMV, de ArrudaCardosoSmithM,BurbanoRR (2006): Interrelationship betweenchromosome8 aneuploidy,C-MYCamplificationandincreasedexpressionin individuals from northernBrazil with gastricadenocarcinoma.World J Gastroenterol 12:6207-621I. CampsJ, AnnengolG, Del Rey J, Lozano J, VauhkonenH, PratE, EgozcueJ, Sumoy L, KnuutilaS, Miro R (2006): Genome-widedifferencesbetween microsatellitestable and unstablecolorectal tumors. Carcinogenesis 27:419-428. CardosoJ, BoerJ, MorreauH, FoddeR (2007): Expressionandgenomicprofilingof colorectalcancer. Biochim Biophys Acta -Rev Cancer 1775:103-137. Chen HL, Chen YC, Chen DS (1996): ChromosomeIp aberrationsare frequentin humanprimary hepatocellularcarcinoma.Cancer Genet Cytogenet. 86:102-1 06. Couturier-Turpin MH, BertrandV, CouturierD (2001): Distal deletionof 1 p in colorectaltumors:an initialeventandora stepin carcinogenesis?Studyby fluorescencein situ hybridizationinterphase cytogenetics.Cancer Genet Cytogenet 24:47-55. DArrigoA, BellucoC, AmbrosiA, Digito M, EspositoG, BertolaA, FabrisM, NofrateV, Mammano E, Leon A, Nitti D, Lise M (2005): Metastatictranscriptionalpatternrevealed by gene expression profiling in primarycolorectalcarcinoma.Int J Cancer 115:256-262. De Angelis PM, Stokke T,Beigi M, Mjaland 0, Clausen OP (2001): Prognostic significance of recurrentchromosomalaberrationsdetectedby comparativegenomic hybridizationin sporadic colorectalcancer.Int J Colorectal Dis 16:38-45. Debiec-RychterM, Sciot R, PauwelsP,SchoenmakersE, Dal Cin P, HagemeijerA (200 1): Molecular cytogeneticdefinitionof threedistinctchromosomearm 1% deletionintervalsin gastrointestinal stromal tumors. Genes Chromosomes Cancer 3226-32. Diep CB, Kleivi K, RibeiroFR, TeixeiraMR.LindgjaerdeOC, LotheRA (2006):Theorderof genetic events associatedwith colorectalcancerprogressioninferredfrom metaanalysisof copy number changes. Genes Chromosomes Cancer 45:3141. Dong SM, TraversoG, JohnsonC (2001): Detectingcolorectalcancerin stool with the use of multiple genetic targets.J Nut1 Cancer Inst 93958-865. DouglasEJ,FieglerH, RowanA, HalfordS, Bicknell DC, BodmerW,TomlinsonW,CarterNP (2004): Array comparativegenomic hybridizationanalysis of colorectal cancercell lines and primary carcinomas.Cancer Res 64:48 17-4825. Fawole AS, SimpsonDJ, RajagopalR, ElderJ, HollandTA, FryerA, Deakin M. ElderJB, FarrellWE (2002): Loss of heterozygosityon chromosome1% is associated with earlieronset sporadic colorectaladenocarcinoma.Int J Cancer 999329433.

REFERENCES

457

Fearon ER, Vogelstein B (1990): A genetic model for colorectal tumorigenesis. Cell 6 l:759-767. Ferti-PassantonopoulouAD, Panani AD, Vlachos JD, Raptis SA ( 1987): Common cytogenetic findings in gastric cancer. Cancer Genet Cytogenel 24:63-73. Fletcher JA, Kozakewich HP, Pavelka K,Crier HE, ShambergerRC, Korf B, Morton CC (199 I): Consistentcytogenetic aberrationsin hepatoblastoma:a commonpathwayof genetic alterationsin embryonalliver and skeletal muscle malignancies?Genes Chromosomes Cuncer 3:3743. Ghadimi BM, Grade M, Liersch T, Langer C, Siemer A, Fuzesi L, Becker H (2003): Gain of chromosome 8q23-24 is a predictivemarkerfor lymph node positivity in colorectal cancer. Clin Cuncer Res 9: 1808- 1814. Gorunova L, Johansson B, Dawiskiba S, Andrkn-SandbergA, Mandahl N, Heim S, Mitelman F ( I 995): Cytogenetically detected clonal heterogeneity in a duodenal adenocarcinoma.Cancer Genet Cytogenet. 82:146-150. GorunovaL, HoglundM, Andrkn-SandbergA, Dawiskiba S, Jin Y, MitelmanF, JohanssonB (1998): Cytogenetic analysis of pancreaticcarcinomas:intratumorhetcrogeneityand nonrandompattern of chromosomeaberrations.Genes Chromosomes Cancer 23:81-99. GorunovaL, ParadaLA, Limon J, Jin Y,Hallen M, HagerstrandI, Iliszko M, WajdaZ, JohanssonB ( 1999): Nonrandom chromosomal aberrations and cytogenetic heterogeneity in gallbladder carcinomas.Genes Chromosomes Cancer 26:3 12-32 I . Grade M, Becker H, Liersch T, Ried T, Ghadimi BM (2006): Molecular cytogcnetics: Genomic imbalancesin colorectal cancer and their clinical impact. Cellular Oncol28:7 1-84. Griffin CA, Hruban RH, Long PP, MorsbergerLA, Douna-lssa F, Ye0 CJ (1994): Chromosome abnormalitiesin pancreaticadenocarcinorna.Genes Chromosomes Cuncer 9:93- 100. Halling KC, French AJ, McDonnell SK, Burgart W, Schaid DJ. Peterson BJ, Moon-Tasson L, Mahoney MR, Sargent DJ, O’Connell MJ, Witzig TE, FarrGH, Goldberg Rh4, Thibodeau SN (1999): Microsatelliteinstability and 8p allelic imbalancein stage B2 and C colorectalcancers. J Natl Cuncer Inst 91 :1295-1 303. Hany MA, Betts DR, Schmugge M, Schqnle E, Niggli FK, Zachmann M, P16ss H-J (1997): A childhood fibrolamellarhepatocellularcarcinomawith increased aromataseactivity and a near triploid karyotype.Med Pediutr Oncol28: 134-1 38. HaradaT, Okita K, Shiraishi K, Kusano N, KondohS. Sasaki K (2002): Interglandularcytogenetic heterogeneity detected by comparativegenomic hybridizationin pancreaticcancer. Cancer Re.? 621835439. HashimotoK, Mori N, TamesaT, OkadaT, KawauchiS, Oga A, FuruyaT, TangokuA, OkaM, Sasaki K (2004): Analysisof DNA copy numberaberrationsin hepatitisC virus-associatedhepatocellular carcinomasby conventional CGH and arrayCGH. Mod Pathol 17:617422. Hecht F, KubanDJ, BergerC, Kaiser-McCawHecht B, SandbergAA (1983): Adenocarcinomaof the gallbladder:chromosome abnormalitiesin a genetic form of cancer. Cancer Genet Cytogenet 8:185-190. Heim S ( I 992): Is cancer cytogenetics reducible to the molecular genetics of cancer cells? Genes Chromosomes Cuncer 5 :188-196. HeinrichMC, BlankeCD, DrukerBJ, CorlessCL (2002a): Inhibitionof KIT tyrosinekinaseactivity:a novel molecular approach to the treatment of KIT-positive malignancies. I Clin Oncol 20: 1692-1 703. HeinrichMC, Rubin BP, Longley BJ, FletcherJA (2002b): Biology and genetic aspects of gastrointestinal stromal tumors:KITactivation and cytogenetic alterations.Hum Puthol33:484-495. HirotaS , Isozaki K, MoriyamaY, HashimotoK, Nishida T, IshiguroS, KawanoK, HanadaM, Kurata A, TakedaM, MuhammadTunioG, MatsuzawaY,KanakuraY,ShinomuraY, KitamuraY ( 1 998): Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors. Science 279:577-580.

458

TUMORS OF M E DIGESTIVE TRACT

HirotoK, Hidenori0, Akiko K, ShigeruS, TadashiK, Tomoo K, FumieH, lssei I, JohjiI, Setsuo H, TatsuhiroS (2007): Genetically distinct and clinically relevant classification of hepatocellular carcinoma:putativetherapeutictargets. Gustroenterology 133:1475-1 486. HoulstonRS, CollinsA, SlackJ, MortonNE( 1992):Dominantgenesforcolorectalcancerarenot rare. Ann Hum Genef 56:99-103. IacopettaB (2002): Are there two sides to colorectalcancer?lnf J Cuncer 101:403408. JiangJK,Chen YJ, Lin CH,Yu IT,Lin JK (2005):Geneticchangesandclonality relationshipbetween primarycolorectalcancersandtheirpulmonarymetastases- an analysisby comparativegenomic hybridisation.Genes Chromosomes Cancer 43:25-36. Johansson B, Bardi G, Heim S, Mandahl N, Mertens F, Bak-Jensen E, Andrkn- Sandberg MitelmanF (1992): Nonrandomchromosomalabnormalitiesin pancreaticcarcinomas.Cancer 69: 1674-1 68 1. JohanssonB, Heim S, MandahlN,MertensF, MitelmanF (1993): Trisomy7 in nonneoplasticcells. Genes Chromosomes Cuncer 6:199-205. JohanssonB, Bardi C, Pandis N, GorunovaL, BEkman PL, MandahlN, Dawiskiba S, AndrinSandbergA, Heim S, MitelamanF (1994): Karyotypicpatternof pancreaticadenocarcinomas correlateswith survival and tumourgrade. lnt J Cancer 5853-13. Kitay-CohenY Amiel A, Ashur Y, Fejgin MD, HcrishanuYAfanasyev F, Bomstein Y, LishnerM (2001): Analysis of chromosomalaberrationsin large hepatocellularcarcinomasby comparative genomic hybridization.Cancer Genet Cytogenef 131:60-64. KitayamaY, lgarashiH, WatanabeF, MaruyamaY, KanamoriM, SugimuraH (2003): Nonrandom chromosomalnumericalabnormalitypredictingprognosisof gastriccancer:a retrospectivestudy of 51 cases using pathology archives. Lab Invesf 83:13I I- 1320. Knosel T, Schluns K, Stein U, Schwabe H, Schlag PM, Dietel M, PetersenI (2003): Genetic imbalanceswith impacton survivalin colorectalcancerpatients.Histopathology 43:323-33 I . Knosel T, SchlunsK, Stein U, SchwabeH, Schlag PM, Dietel M, PetersenI (2004): Chromosomal alterationsduring lymphatic and liver metastasis formation of colorectal cancer. Neupiusiu 6:23-28. Knosel T, SchlunsK, Dietel M, PetersenI (2005): Chromosomalalterationsin lung metastasesof colorectalcarcinomas:associationswith tissue specific tumordissemination.Clin Exp Metustusk 221533-538. KonstantinovaLN, FleishmanEW, Knisch VI, PerevozchikovAG, KopninBP (1991): Karyotypic peculiaritiesof humancolorectaladenocarcinomas.Hum Genet 86:49 1-496. Kowalski J, MorsbergerLA, Blackford A, Hawkins A, Ye0 CJ, HrubanRH, Griffin CA (2007): Chromosomal abnormalitiesof adenocarcinomaof the pancreas: identifying early and late changes. Cancer Genet Cytogenet 178:26-35. Leggett BA, Devereaux B, Biden K, Searle J, Young J, Jass J (2001): Hyperplasticpolyposis: association with colorectalcancer.Am J Surg Puthol25:177-1 84. Leslie A, CareyFA, PrattNR,Steele RJC(2002): The colorectaladenoma+arcinomasequence.Br J Surg 89:845-860. Lin JK, Chang SC, Yang YC, Li AF-Y (2003): Loss of heterozygosity and DNA aneuploidy in colorectal adenocarcinoma.Ann Surg Oncol 10:1086-1094. Lips EH, de GraafEJ,TollenaarR, van Eijk R, Oosting J, SzuhaiK, KarstenT, Nanya Y, OgawaS, van de Velde CJ, EilersPHC, van WezA T, MorreauH (2007): Single nucleotidepolymorphism arrayanalysisof chromosomalinstabilitypatternsdiscriminatesrectaladenomasfromcarcinomas. J Path01 212~269-277. LowichikA, SchneiderNR, TonkV,AnsariMQ,TimmonsCF( 1996):Reportof a complexkaryotype in recurrentmetastatic fibrolamellarhepatocellularcarcinoma and a review of hepatocellular carcinomacytogenetics. Cancer Genet Cytogener 88: 170-1 74.

REFERENCES

459

Mao X, Hamoudi RA, TalbotlC, Baudis M (2006):Allele-specific loss of heterozygosity in multiple colorectaladenomas:towardan integratedmolecularcytogenetic map11. Cancer Genet Cytogenet 167:1-14. MascarelloJT,KrousHF(1 992): Second reportof a translocationinvolving 19q13.4 in a mesenchymal hamartomaof the liver. Cancer Genet Cytogenez 58: 141-142. Meijcr GA, Hermsen MAJA. Baaak JPA, van Diest PJ, Meuwissen SGM, Belien JAM (1998): Progressionfrom colorectal adenomato carcinomais associated with non-randomchromosomal gains as detected by comparativegenomic hybridization.J Clin Pathof 51 :901-909. Misawa S, Horiike S, Taniwaki M, Tsuda S, OkudaT, Kashima K. Abe T, SugiharaH, Noriki S, FukudaM (1990): Chromosomeabnormalitiesof gastric cancer detected in cancerouseffusions. Jpn J Cancer Res 8 1:148-152. MitelmanF, MarkJ, Nilsson PG, Dencker H, Nonyd C, TranbergKG ( I 974): Chromosomebanding patternin human colonic polyps. Hereditas 78:63-68. MitelmanF. JohanssonB, MertensF, editors(2008): MitelmanDatabaseof ChromosomeAberrations in Cancer.http://cgap.nci.nih.gov/ChromosomeslMitelman. Moinzadeh P, Breuhahn K. Stiitzer H, SchirmacherP (2005): Chromosome alterationsin human hepatocellularcarcinomascorrelatewith aetiology andhistologicalgrade:resultsof an explorative CGH meta-analysis.Br J Cancer 92:935-941. Muleris M, Salmon R-J, Dutrillaux B (1 990): Cytogeneticsof colorectal adenocarcinomas.Cancer Genet Cytogenet 46: 143-1 56. Nakao K, Mehta KR, FridlyandJ, Moore DH, Jain AN, Lafuente A, Wiencke JW,TerdimanJP, Waldman FM (2004): High-resolution analysis of DNA copy numberalterationsin colorectal cancer by array-basedComparativegenomic hybridization.Carcinogenesis 25: 1345- 1357. Nishida K, TakanoH, YonedaM, OhtsukiT, FujiiM, TerasawaY, YamaneE, NishiokaB, NamuraK, YoshikawaT (1995): Flow cytometricanalysisof nuclearDNA contentin tissues of colon cancer using endoscopic biopsy specimens. J Surg Oncol59: I8 1-1 85. Nishida N, NishimuraT, Ito T, KomedaT, FukudaY, Nakao K (2003): Chromosomalinstabilityand human hepatocarcinogenesis.Histol Histopathol 18:897-909. Ottini L, Falchetti M, Lupi R, Rizzolo P, Agnese V, Colucci G, Bazan V, Russo A (2006): Patterns of genomic instability in gastric cancer: clinical implications and perspectives. Ann Oncol 17~97-102. PananiAD, Ferti AD, Avgerinos A. Raptis SA (2004): Numerical aberrationsof chromosome8 in gastric cancer detected by fluorescence in situ hybridization.Anticancer Res 24: 155-159. ParadaLA, HallCnM, TranbergKG, Hagerstrand1, Bondeson L, Mitelman F, JohanssonB ( 1998): Frequentrearrangementsof chromosomes1,7, and8 in primarylivercancer.Genes Chromosomes Cancer 23~26-35. Parada LA, Maranon A, Hallen M, Tranberg K-G, Stenram U, Bardi G, Johansson B (1999): Cytogenetic analyses of secondary liver tumors reveal significant differences in genomic imbalances between primary and metastatic colon carcinomas. Clin Exp Melastasis 17:471479. ParadaLA, Limon J, Iliszko M, CzaudernaP, Gisselsson D, Hoglund M, KullendorFfCM, Wiebe T, Mertens F. Johansson B (2000): Cytogenetics of hepatoblastoma:furthercharacterizationof Iq rearrangementsby fluorescence in situ hybridization:an internationalcollaborative study. Med Pediatr Oncol34: 165- 170. Paredes-ZaglulA, Kang JJ,Essig YP, Mao WG, lrby R, Wloch M, YeatmanTJ (1998): Analysis of colorectalcancerby comparativegenomic hybridization:evidence for inclusion of the metastatic phenotype by loss of tumor suppressorgenes. Clin Cancer RCS 42379-886. Patil MA, Gutgemann1, Zhang J, Ho C, Cheung ST, Ginzinger D, Li R, Dykema KJ, So S, Fan ST, KakarS,Furge KA, ButtnerR, Chen X (2005): Array-basedcomparativegenomic hybridization

460

TUMORS OF THE DIGESTIVE TRACT

reveals recurrentchromosomalaberrationsand Jab1 as a potentialtargetfor 8q gain in hepatocellular carcinoma. Carcinogenesis 26:2050-2057. Platzer UpenderMB, Wilson K. Willis J, LutterbaughJ, NorrattiA, Willson JKV, Mack D,Rid T, Markowitz S (2002): Silence of chromosomal amplifications in colon cancer. Cancer Res 6 2 1134-1 138. RajaramV, Knezevich S, Bove KE,PerryA, Pfeifer JD (2007): DNA sequence of the translocation breakpointsin undifferentiatedembryonalsarcomaarisingin mesenchymalhamartomaof the liver harboringthe t( 1 1 ;19)(q1 I ;q 13.4) translocation.Genes Chromosomes Cancer 46508-51 3. RakhejaD, MargrafLR, TomlinsonGE, SchneiderNR (2004):Hepaticmesenchymalhamartomawith translocation involving chromosome band 19ql3.4: a recurrent abnormality.Cancer Genet Cytogenet I53:60-3. Rao PH, Mathew S, Lauwers G, Rodriguez E, Kelsen DP, Chaganti RSK (1993): Interphase cytogenetics of gastric and esophageal adenocarcinomas.Diagn Mol Pathol2:264-268. Rashid A. Houlihan P, Booker S, Petersen G, Giardiello F, Hamilton S (2000): Phenotypic and molecularcharacteristicsof hyperplasticpolyposis. Gastroenterology 1 19:323-332. Reichman A, Levin MartinP, Levin B (1981): Chromosomalbandingpatternsin humanlargebowel cancer. lnt J Cancer 28:43 1440. Ried T, KnutzenR, SteinbeckR, BIegen H, Schrock E, Heselmeyer K, DumanoirS, Auer G (1996): Comparativegenomic hybridizationreveals a specific patternof chromosomal gains and losses duringthe genesis of colorectal tumors. Genes Chromosomes Cancer 15234-245. Rijken AM, Hu J, PerlmanEJ, MorsbergerLA, Long P, Kern SE, HrubanRH, Ye0 CJ, GriffinCA ( 1999): Genomic alterationsin distal bile duct carcinomaby comparativegenomic hybridization and karyotypeanalysis. Genes Chromosomes Cancer 26:185-1 9 I . RodriguezE, Rao PH, Ladanyi M, Altorki N, Albino AP, Kelsen DP, JhanwarSC, ChagantiRSK (1990): 1 lp13-15 is a specific region of chromosomal rearrangementin gastric and esophageal adenocarcinomas.Cancer Res 50:6410-64 16. Rodriguez E, ReuterVE, Mies C, Bosl GJ, ChagantiRSK (1991): Abnormalitiesof 2q: a common genetic link between rhabdomyosarcomaand hepatoblastoma?Genes Chromosomes Cancer 3: 122-127. RubinBP, HeinrichMC, CorlessCL (2007):Gastrointestinalstromaltumour.Lancet 369:1731-1 741. Saffroy R, Lemoine A, Debuire B (2006): Mechanisms of hepatocarcinogenesis. Atlas Genet Cytogenet Oncol Haematol. http:IIAtlasGeneticsOncology.org/Deep/HesisID20055.html. Sainati L, Leszl A, Stella M, Montaldi A, Perilongo G, Rugge M, Bolcato S, Iolascon A, Basso G (1998): Cytogenetic analysis of hepatoblastoma:hypothesis of cytogenetic evolution in such tumors and results of a multicentricstudy. Cancer Genet Cytogenet lW39-44. SchneiderNR, Cooley LD, Finegold MJ, Douglass EC, Tomlinson GE (1997): The first recumng chromosometranslocationin hepatoblastoma:der(4)t(I :4)(q1 2;q34). Genes Chromosomes Cancer 19:291-294. SerucaR,CastedoS, CorreiaC,Gomes P, CarneiroF. SoaresP, de JongB, Sobrinho-SimoesM (1993): Cytogenetic findings in eleven gastric carcinomas.Cancer Genet Cytogenet 68:4248. Sharif K, Ramani P, Lochb6hlerH, GrundyR, de Ville de Goyet J (2006): Recurrentmesenchymal hamartomaassociated with 19q translocation.A call for more radical surgical resection. Eur J Pediatr Surg 16:64-67. Shroy P, Cohen A, WinawerS, FriedmanE (1988): New chemotherapeuticdrugsensitivity for colon carcinomasin monolayerculture. Cancer Res 48:323&3244. Simon D, Munoz SJ, MaddreyWC, Knowles BB (1990): Chromosomalrearrangementsin a primary hepatocellularcarcinoma. Cancer Genei Cytogenet 45:255-260.

REFERENCES

461

SoukupSW, LampkinBL ( 1991): Trisomy 2 and 20 in two hepatoblastomas.Genes Chromosomes Cancer 3:23 1-234. Suzuki K, OhnamiS, TanabeC, SasakiH,Yasuda J, Katai H, YoshimuraK, TeradaM, PeruchoM, YoshidaT (2003):Thegenomicdamageestimatedby arbitrarilyprimedPCR DNA fingerprinting is useful for the prognosisof gastriccancer.Gastroenlerology 25: 1330-1 340. TanakaK, YanoshitaR, Konishi M, OshimuraM, Maede Y,MoriT, Miyaki M (1993):Suppressionof tumorigenicityin human colon carcinomacells by introductionof normal chromosome lp36 region. Oncogene 8:2253-2258. ThorstensenL, Qvist H, Heim S, LiefersGJ,NeslandJM,GierckskyKE,LotheRA (2000):Evaluation of 1 p losses in primarycarcinomas,local recurrencesand peripheralmetastasesfromcolorectal cancerpatients.Neoplasia 2:5 14-522. TomlinsonGE, DouglassEC, Pollock BH, Finegold MJ, SchneiderNR (2005): Cytogeneticevaluation of a large series of hepatoblastomas:numerical abnormalitieswith recurringaberrations involving lq 12-q21. Genes Chromosomes Cancer 44:177- 184. Tonouchi H, MatsumotoK, KinoshitaT, ltoh H, Suzuki H ( I 998): Prognostic value of DNA ploidy univariateandmultivariateanalysis.Dig Surg 15:687492. patternsof colorectaladenocarcinoma: Van CutsemE,NordlingerB, Adam R, Kohne C, Poston G. Ychou M, RougierP (2006): Towardsa pan-Europeanconsensuson the treatmenlof patientswith colorectallivermetastases.Eur J Cancer 42:2212-2221. WeberRG, PietschT,von SchweinitzD, LichterP (2000):Characterization of genomic alterationsin hepatoblastomas: a rolefor gainson chromosomes8q and20 as predictorsof pooroutcome.Am J fathol 157571-578. Weiss MM, KuipersEJ, Postma C, SnijdersAM, Siccama I, Pinkel D, WestergaJ, Meuwissen SG, AlbertsonDG, MeijerGA (2003):Genomicprofilingof gastriccancerpredictslymph node status and survival.Oncogene 22: L 872-1 879. WernerM, Nolte M, GeorgiiA, KlempnauerJ (1 993): ChromosomeI abnormalitiesin hepatocellular carcinoma.Cancer Genet Cytogenet66:130. Wong N, Lai P, Lee SW, Fan S, PangE, Liew CT,ShengZ, Lau JW,JohnsonPJ (1999): Assessmentof genetic changes in hepatocellularcarcinomaby comparativegenomic hybridizationanalysis: relationshipto disease stage, tumor size, and cirrhosis.Am J Pathol 154:37-43. Woodford-RichensKL,Rowan AJ, Gorman P, HalfordS, Bicknell DC, Wasan HS, Roylance RR, BodmerWF, Tomlinson Ip (2001): SMAD4 mutationsin colorectalcancerprobablyoccur before chromosomalinstability,but afterdivergenceof the microsatelliteinstabilitypathway.f roc Natl Acad Sci USA 98:97 19-9723. Xia J, Xiao S, ZhangJ ( I 999): DirectchromosomeanalysisandRSH studyof primarygastriccancer. Ulonghua Bong Liu Za Zhi 21 :345-349. Xiao S, Geng J-S, Feng X-L,Liu X-Q, Liu Q-Z, Li P (1992): Cytogeneticstudiesof eight primary gastriccancers. Cancer Genet Cytogenet 58379-84. ZankeB W,GreenwoodCM, RangrejJ, KustraR, TenesaA, FarringtonSM, PrendergastJ, Olschwang S, ChiangT,CrowdyE, FerrettiV,LaflammeP, Sundararajan S, Roumy S, OlivierJF,RobidouxF, Sladek R, MontpetitA. Campbell P, Bezieau S, O’Shea AM, Zogopoulos G, CotterchioM, Newcomb P. McLaughlin J, YounghusbandB, Green R, Green J, PorteousME, CampbellH, Blanche H, SahbatouM, TubacherE, Bonaiti-PelliCC, BuecherB, Riboli E, KuryS, ChanockSJ, PotterJ, ThomasG, GallingerS, HudsonTJ,Dunlop MG (2007): Genome-wideassociationscan identifies a colorectalcancersusceptibilitylocus on chromosome 8q24. Nut Genet 39989-994. Zhou W, GoodmanSN, GaliziaG, Lieto E, FerraraccioF, Pignatelli C, PurdieCA, Piris3, Moms R, Harrison DJ, Pay PB, Cuilford A, Romans KE, Montgomery EA, Choti MA, Kinzler KW, Vogelstein B (2002): Countingalleles to predict recurrenceof early-stagecolorectal cancers. Lancet 359:219-225.

I CHAPTER 14

Tumors of the Urinary Tract PAOLA DAL CIN and AZRA

H.LlGON

In this organsystem, extensive cytogeneticdata are availableonly for the most common tumors,those of the kidney and bladder.Very few ureteraland urethralneoplasms with chromosomeabnormalitieshave been described(Mitelmanet al., 2008).

KIDNEY The classification of renal tumorshas been an evolving process over many years (Weiss et al., 1995; Kovacs et al., 1997; Storkel et al., 1997; Fleming and O’Donnell, 2000). Throughinternationalconsensus,they havenow come to be classifiedby the WorldHealth Organization(WHO) using a scheme that incorporatesboth morphologic and genetic characteristics(Eble et al., 2004). Unfortunately,the accumulationof cytogenetic and clinico-pathologicdata for some lesions has been slowed by their relative rarity, for example,medullarycarcinoma,mucinous tubularand spindle cell renal cell carcinomas, and metanephricadenomas. Most of the 1700 cytogeneticallyabnormalkidney tumorsare renal cell carcinomas (RCC), and also benign renal tumorsare now increasinglybeing subjectedto systematic cytogeneticanalysis.Extensivereviews of the field were providedby Dal Cin et al. (1988), Walter et al. (1989a), Meloni et al. (1992a), Kovacs (l993), Van Poppel et al. (2000), Weinsteinand Dal Cin (2001), Meloni-Ehrig(206)2), and Davis et al. (2003). Trisomy 7 was observed as the sole abnormalityin three of the seven cases of renal angiomyolipoma so far reported.However, because cells carryingthis abnormalityhave also been detected in both neoplasticand non-neoplasticrenal tissues as well as in other tumorsandnon-neoplasticlesions (Johanssonet al., 1993),it is highly questionablewhether 7 shouldreally be viewed as typicalof this type of benigntumor.Involvementof 12q was observed in two cases, but whetheror not 12q rearrangementsare unique to a subset of angiomyolipomasremainsto be clarified(Debiec-Rychteretal., 1992;Wullichet al., 1997). Thepresenceof bilateralor multifocalangiomyolipomasof thekidneyscan also be a feature of tuberoussclerosis,an autosomaldominant,geneticallyheterogeneousdisease featuring

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Cuncer Cytogenefics. Third Edition. edited by Sverre Heim and Felix Mitelman Copyright 0 2009 John Wiley & Sons, Inc.

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multiplebenigntumorsandcausedby mutationsin eitherof the tuberoussclerosiscomplex genes, TSCI (9q343 or TSC2 (16~13.3)(Crhoet al., 2006). Froma cytogeneticstandpoint,oncocytomas can be dividedintothreegroups:thosewith loss of chromosomes1 and/or14 and one sex chromosome,most often the Y chromosome of 1 Iql3 (Crottyet al., 1992;Federetal., 2000; Paneretal., 2007); thosewithrearrangement (Walteret al., 1989b), with t(9;ll) and t(5;l I ) among the most frequenttranslocations observed(Fig. 14.1);andthosewith heterogeneousabnormalities,includingbothnumerical and structuralaberrations(Jhanget al., 2004). No specific genes involved in oncocytoma developmenthave yet been described. Renal oncocytosis is a relativelyraredisorderthatfeaturesmultipleoncocytomas.Onlya singletumorfroman individualwith sporadiconcocytosishasbeen studiedcytogenetically; that tumor showed monosomy for chromosomes 1, 14, and 21, as well as loss of the Y chromosome(Al-Saleem et a]., 2004). These cytogenetic findings are similarto those observedin solitaryoncocytoma.Multipleoncocytomascan also occur in familial form, as the rare familial renal oncocytoma. One such family showed a constitutionalt(8;9) (q24;q34) in the individualswith renal oncocytoma (Teh et al., 1998). Multipleoncocytomas may also be part of the Birt-Hogg-Dube syndrome, which shows incomplete penetranceand is caused by mutationsin the FLCN (or BHD) gene at 17pl1.2 (Khoo et al., 2001). The renal neoplasms typically present as hybrid oncocytic tumors (with featuresof oncocytomaandchromophobeRCC),or they can presentas chromophobeRCC, oncocytoma,clear-cellRCC,and,occasionally,as papillaryRCC(Pavlovichet al., 2002). Only three metanephric adenomas with abnormalkaryotypeshave been described. 47,X,-Y, 7, 17 was reportedby Brown et al. (1996). A possible relationshipbetween this tumortype and papillaryRCC (see below) was suggestedbecause of the finding by fluorescencein situ hybridization(FISH)of gain of chromosomes7 and 17 in 7 of 1 1 tumors (Brown et al., 1997). However, Brunelli et al. (2003) did not confirmthis link in a study of 70 metanephricadenomas.A 2p23 deletion was reportedas the single abnormality

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der(9)

der(5)

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der(l1)

der(l1)

FIGURE 14.1 A t(9;Jl)(p23;qJ3)(a) and a t(S;Il)(q35;q13)(b) are among the translocations involving I Iq I3 in oncocytomas.

most frequent

KIDNEY

465

by Stummet a]. (1999), andthe possibilityof a tumorsuppressorgene (TSG)in this interval was suggested by microsatelliteanalysis (Pesti et al., 2001). Lerutet al. (2006) described a 46,XX,t(1;22)(q22;q13),t(15;16)(q21;p13) karyotypein a large metanephricadenoma from a 24-year-oldprimigravida. Small, curticul epithelial tumurs are common incidental findings at postmortem examinationsand in nephrectomy specimens, but distinguishingbetween benign and malignanttumorsis problematic.Small papillarytumorsare the most common, and the consensus among pathologistsis that the tumorsare benign, that is, papillaryadenomas when they are less than 5 m m in diameter with papillaryor tubulararchitectureof low nucleargrade(Ebleet al.. 2004). The cytogeneticfindingsin adenomasaresimilarto those of papillary RCC and include trisomy for chromosomes 7 and 17 and loss of the Y chromosome(Fig. 14.2). The presenceof additionalkaryotypicabnormalitiesis highly suggestive of malignancy, however (Dal Cin et al., 1989; Kovacs et al., 1991b; Presti et al., 1991; Van Poppel et al., 2000). Papillary renal cell carcinoma is the second most common type of RCC, comprising 10- 15% of all renalparenchymalepithelialtumors.A combinationof trisomyor tetrasomy 7, trisomy 17, and loss of the Y ch