Cytogenetic and Clinical Investigations in 76 Cases with Therapy-related Leukemia and Myelodysplastic Syndrome

Alessandra Iurlo, Cristina Mecucci, Angeline Van Orshoven, Jean-Louis Michaux, Marc Boogaerts, Lucien Noens, Andr~ Bosly, Andries Louwagie, and Herman Van Den Berghe

ABSTRACT: Clinical, cytomorphologic, and cytogenetic investigations were carried out in a series of 76 secondary MDS and ANLL. Chromosome abnormalities were more frequent in patients with a history of mult iple myeloma or macroglobulinemia (92%) and myeloproliferative disorders (82%) than in patients with previous breast cancer 140%). The secondary hematologic malignancies were mostly a trilineage bone marrow disorder. The most commonly found cytogenetic anomaly was monosomy 7, followed by total or partial loss of chromosome 5. In addition six other chromosomes, i.e., chromosome 3, 8, 9, 12, 17, and 21 seemed to be consistently inw~lved in the pathogenetic mechanisms of secondary leukemia and MI)S.

I N T R O D U C T I O N

T h e d e v e l o p m e n t of a m y e l o d y s p l a s t i c s y n d r o m e (MDS) a n d / o r acu te l e u k e m i a (ANLL) af ter c h e m o t h e r a p y a n d / o r r a d i o t h e r a p y for n e o p l a s t i c a n d n o n n e o p l a s t i c d i s o r d e r s r e p r e s e n t s t he m o s t i m p o r t a n t c o m p l i c a t i o n for p a t i e n t s s u c c e s s f u l l y

t rea ted . S e c o n d a r y ANLL is u s u a l l y d i s t i n g u i s h a b l e f rom de n o v o ANLL on b o t h m o r p h o -

logic a n d c l i n i ca l g r o u n d s in t ha t s -ANLL is of ten p r e c e d e d by an MDS. A c o m p l e t e r e m i s s i o n is r a re ly o b t a i n e d w i t h c o n v e n t i o n a l c h e m o t h e r a p y . C h r o m o s o m e a n o m a - l ies t y p i c a l l y i n v o l v i n g c h r o m o s o m e s 5 a n d / o r 7 are p r e s e n t in m o r e t h a n 80% of

cases [1 -3] . T h e a i m of th i s s t u d y was to i nves t i ga t e c h r o m o s o m e a n o m a l i e s in 68 p a t i e n t s in

w h o m MDS or ANLL d e v e l o p e d af ter c h e m o - a n d r a d i o t h e r a p y for h e m a t o l o g i c or

From the Center for Human Genetics (A. I., C. M., H. V. D. B.), Central Clinical Laboratory (A. V. O.], and Department of Haematology (M. B.J, University of Leuven, Belgium, the Department of Hematology, Universite de Louvain, Belgium (J-L. M.), the Department of Hematology, University of Gent, Belgimn (L. N.), the Department of Internal Medicine, Universit0 de Louvain h Mont-Godinne, Yvoir, Belgium (A. B.), and the Department of Hematology, Brugge, Belgium (A. L.). Present addresses are: A. I.. Istituto di Scienze Mediche, University of Milano, Italy; C. M.. Clinica Medica 1, University of Perugia, Italy.

Address reprint requests to: Dr. /3. Van Den Berghe, Center for Human Genetics, Herestraat 49, B-3000 Leuven, Belgium.

Received February 16, 1989; accepted May 30, 1989.

227

© 1989 Elsevier Science Publishing Co., Inc. Cancer Genet Cytogenet 43:227 241 (19891 655 Avenue of the Americas, New York, NY 10010 0165~4608/89/$03.50

228 A. Iurlo et al.

solid tumors. Eight addi t ional cases of possibly induced ANLL or MDS inc luded four pat ients treated with cyc lophosphamide for mul t ip le sclerosis or au to immune thyroidi t is , three workers previously exposed to chemical toxic agents, and one pat ient who received thorotrast for diagnostic purposes. Analysis of the cytogenetic data from this large series of secondary MDS and ANLL compared to data from the l i terature proved useful for a better del ineat ion of the most consis tent ly occurring chromosome aberrat ions in these hematologic malignancies. Information on survival was also obtained.

MATERIALS AND METHODS

Seventy-six pat ients who deve loped s-ANLL and/or s-MDS were s tudied between 1973 and May 1987 at the Universi ty of Leuven. Seventy-two patients had a history of t reatment wi th chemotherapy and/or radiotherapy, while four had a documented exposure to other toxic agents.

Clinical data col lected were sex, age, pr imary disease, treatment, interval t ime before the appearance of secondary neoplasia, t reatment for second malignancies, and survival. In 21 cases a review of bone marrow smears had to be made, with the aim of classifying MDS and ANLL according to FAB criteria [4-6]. For the other cases, classif icat ion had al ready been done in accordance with the FAB criteria.

Chromosome analysis at the t ime of diagnosis of the secondary blood disorder was done on bone marrow (BM) and/or per ipheral blood (PB) from 24-48-hour uns t imula ted and control s t imulated cultures with methotrexate synchronizat ion. Karyotypes were obtained after R banding with acr idine orange. As a rule, at least 25 metaphases were analyzed, of which ten were fully karyotyped. Chromosome abnormal i t ies are descr ibed according to the ISCN [7]. The criteria adopted at the First Internat ional Workshop on Chromosomes in Leukemia were used for identifi- cat ion of abnormal clones [8]. Single abnormal cells were not taken into considera- tion. Cytogenetic results were correlated with treatment, t ime elapsed since diagnosis of the pr imary disease, and survival. Survival was also analyzed in relat ion to age, sex, type of disease, and treatment. Statistical analyses were made using a log-rank test.

RESULTS

Clinical Characteristics

The cl inical characteris t ics of 76 pat ients are l isted in Table 1. There were 40 men and 36 women with age ranging from 18 to 89 years at the t ime of diagnosis of the secondary disease (median age 57.5 years, mean age 55.5 years). The mean age was lower in pat ients wi th previous Hodgkin 's disease (40.3 years). The cases were d is t r ibuted as follows: 19 Hodgkin ' s disease, five non-Hodgkin 's lymphoma, 12 mul t ip le myeloma, two Waldens t r6m's macroglobul inemia, 16 polycythemia vera, one essential thrombocythemia , ten breast cancer, three other solid tumors, three mul t ip le sclerosis, one au to immune thyroidi t is , and four exposed workers. Seventy- two cases had a documented history of chemotherapy and/or radiotherapy: 29 pat ients received only chemotherapy, ten only radiotherapy, and the rest had rad io therapy (RT) and chemotherapy. The mean t ime elapsing between first disease and the date of diagnosis of secondary bone marrow neoplas ia in the patients wi th documented previous therapy was 7.1 years (range 1-21 years); median t ime was 6 years. The mean t ime was longer in patients wi th a previous myeloprol i fera t ive d isorder (11.4 years). In the patients who received only radiotherapy, the mean

Therapy-re la ted Leukemia and MDS 229

elapsing t ime was 9.3 years; in patients who received only chemotherapy it was 7.3 years, and in pat ients who received both it was 6.3 years.

With regard to the last four patients, one had received thorotrast 29 years before. Three cases were workers exposed to aromatic: hydrocarbons.

The secondary bone marrow disorder was a myelodysplas t ic syndrome in 29 cases and acute non lymphocy t i c leukemia in 47 cases. Twenty-seven of these leukemias (57.4%) were preceded by a pre leukemic stage, the median durat ion of which was 5.7 months (range 1-23 months).

Thirty-five pat ients were treated for their secondary disorder with s tandard protocols for myelo id leukemia, cytosine arabinoside (ara-C), 6-mercaptopurine, and thioguanine; one {case 7) also received a bone marrow transplant (BMT). Three other cases received BMT as a first t reatment (cases 12, 69, and 75), and the rest received only suppor t ive care. Median survival was short {7 months) and independen t of age, sex, type of pr imary disease, e lapsing time, and treatment.

Cytomorphologic Findings In all cases, an a t tempt was made to assign classification according to the FAB criteria. Patients classified as having s-MDS had less than 30% blasts in the marrow, whi le diagnosis of s-ANLL was made when the percentage of blasts was greater than 30% in bone marrow. The range of blasts in the patients with s-MDS was 5 20%, whi le in s-ANLL the percentage ranged from 31% to 80%. Among 47 ANLL patients, type M2 was most common (15 cases), fol lowed by M4 (nine cases), M6 (four cases), M1 (two cases), M5 (one case), and M7 (one case). No cases of M3 were observed. The remaining 15 cases were unclassif iable according to FAB criteria. Among 21 cases that could be analyzed, seven presented increased cellulari ty, six normocel lular i ty , and eight hypocel lu lar i ty . Myelodysplas t ic aspects inc luding megaloblast ic red series, hypogranula t ion, and pseudo-Pelgerat ion of granulocytic ce;!s, and small s ized and megaloblast ic megakaryocytes were found in most cases of s-ANLL. No Auer rods were observed.

Cytogenetic Investigations Karyotypes were successful ly obtained in all cases (Table 2). Chromosome abnormal- ities were present in 58 pat ients (76.3%). The dis t r ibut ion of numerical and structural aberrat ions is repor ted in Figure 1. Involvement of chromosomes 5 and/or 7 was present in 42 out of 58 cases (72.4%) with abnormal karyotypes. Monosomy of chromosomes 7 as the only change (seven cases) or with other abnormal i t ies (13 cases) was the most frequent finding (34.4% of abnormal cases). The second most commonly affected chromosome was 5: ten patients had monosomy (17.2% of abnormal cases) and 16 had structural rearrangements (27.5% of abnormal cases). Chromosomes 3 and 12 were consis tent ly involved in structural aberrations. Tr isomy 8 was present in seven out of 76 cases. Chromosome 17 was rarely involved, in contrast to what has been suggested by other investigations [2, 22]. Furthermore, other abnormali t ies , such as t(8;21), t(15;17), and inv(16) typica l ly associated with subgroups of de novo leukemia, were not observed in our series. In the total series, 19 out of 76 showed a normal karyotype {NN), only abnormal mitosis (AA) were observed in 45 cases, and a mixture of abnormal and normal mitoses were observed in 12 cases (AN).

Cases wi th only a normal karyotype showed the highest survival from diagnosis (10 months), whi le the group with monosomy 7 and the group with complex aberrat ions showed a survival of 7 months and 5 months, respect ively (p < 0.0257) (Fig. 2).

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234

T a b l e 2 C y t o g e n e t i c a n a l y s i s

Pat ient Date Sample Cul tu re (hr)

1 5/81 BM 48 2 10/80 BM 48 3 5/77 BM 48

4 8/81 BM 5 11/81 BM

Karyotype Percent ~

4 5 , X Y , - 7 100 46,XX 100 47,XX, 3 , - 1 7 , + m a r l , + m a r 2 , + m a r 3 40 4 6 , X X , - 3 , - 1 7 , - 1 1 , 60

+ m a r l , + mar2, + mar4 48 4 5 , X X , - 7 100 48 45-50,XY, + Y , - 5 , - 7 , - 18,t(19;?) 50

(q?;?),t(19;?)(q?;?),mar1,+ 5mar 45-50,XY, + Y , - 5,del(7)(q21q33), 29

t(19;?)(q?;?),t(19;?)(q?;?), + 5mar 45-50,XY,+ Y , - 5,del(7)(q21q33), 21

t(12;?)(p?;?),t(19;?)(q?;?), t(19;?)(q?;?), + m a r l

72 + PHA 46,XY 46 54

6 4/82 PB

7 3/85 BM 48 8 3/82 BM 48

9 2/83 PB 48

10 1/85 BM 48 11" 6/84 BM 48 12 12/81 BM 48 13 2/79 BM 48 14 4/86 BM 48 15 11/82 BM 48 16 8/79 BM 48 17" 85 BM 48

18 8/81 BM 48 PB 48

19 5/87 BM 48

20 9/78 BM 48

21 3/85 BM 24 22 11/83 PB 48 23 1/81 BM 48 24 10/84 BM 24

25 4/77 BM 48

4 7 - 4 8 , Y , ( - X ) , - 8 , + m a r l , + mar2 ,+ mar3

46,XX 100 45 ,XY, - 5 , - 21,der(4),+ m a r l 30 46 ,XY, -5 , 21 ,de r (4 ) ,+mar1+mar2 20 46 ,XY, - 5 , - 8 , - 1 9 , - 21 ,der(4), 30

+ mar3, + mar4, + mar6 46 ,XY, - 5 , - 8 , - 1 9 , - 21,der(4), 20

+ mar3 ,+ mar4 ,+ mar5 69 ,XX,+X,+ 1,+ 2,+ 3 , + 4 , + 8 , + 8, 50

+ 1 0 , + 1 0 , + 1 1 , + 1 3 , + 1 4 , + 1 4 , + 1 5 , + 1 7 , + 1 8 , + 1 9 , + 2 0 , + 2 0 , + 2 1 , + 2 2 , + 2 2 , + m a r

73 ,XX,+X,+ 1,+ 2,+ 3 , + 4 , + 6 , + 6, 50 + 7 , + 8 , + 1 0 , + 1 1 , + 1 1 , + 1 3 , + 1 3 , + 1 4 , + 1 5 , + 1 5 , + 1 7 , + 1 8 , + 1 8 , + 19 ,+20 ,+ 2 0 , + 2 1 , + 2 2 , + 2 2 , + mar

46,XY,del(7)(p12p21) 100 46,XX,t(1;3)(p36;q21} 100 46,XX 100 45,XY, 7 100 46,XY 100 46,XX 100 46,XX 100 45 ,XY, - 16,t(3;9)(p21;q21), 100

inv(5)(q14q35),t(6;16)(p22;q21) 46,XX,t(3;8)(q26;q23),t(9p15q),+ f 40 46,XX,t(1;?)(q?;?),t(3;8)(q26;q23), 40

t (9p15q) ,+f 4 4 , X Y , - 5 , - 7 , - 1 2 , - 1 8 , 87

t(1;10)(p21;p12),del(16)(p?), + m a r l , + mar2

43-46 ,XY,- 2 , ( - 3),+ der(19), 100 [+der (19) ] , ( - 12) , ( - 13 ) , -13 , + mar

46,XX 100 45 ,XX, - 7 100 46,XY 73 46,XY 8O 4 5 , X Y , - 7 18 45,XX, 7 60 4 6 , X X , - 7 , + m a r 1 40

Table 2 Continued

Patient Date Sample Culture (hr)

26 3/86 BM 48 27 9/82 PB 48

6/83 BM 48

28 5/84 PB 24

29 10/86 BM 24

30* 5/86 BM 24

31 4/79 BM/PB 48

32 12/85 BM 48

33 11/83 BM 48

34 1/80 BM 48

35 6/86 BM 24

36 10/80 BM/PB 48

37 5/82 BM 48 38 4/79 BM 24 39 5/82 BM 72 40* 9/79 BM 48

3/81 PB 48

41" 6/77 BM 72 42* 8/84 BM/PB 48 43* 4/79 BM/PB 48

44* 6/85 BM/PB 48 45* 2/74 BM/PB 48 46 3/78 BM 48 47* 3/85 BM/PB 24 48 5/83 PB 48 49* 9/82 BM 48

50* 3/85 BM 48

51" 8/83 BM 48

10/84 BM 48

7/85 BM 48

Karyotype

46,XX 46,XX 46,XX,i(7q/ 46,XX 46,XX,del(1)(q?),i(7q) 46,XY,del(2)(q24),t(3q-;3q +) 46,XY,t(3q-;3q +) 46,XY 45,XY,del(3)(p14),- 5,+ f 43 ,XY,2p+, -3 , - 7,-20,

t(1;11)(q12;q14),der(4), inv(5)(q12q32),Sq+,del(11)(q14), 12p+

46,XY 45,XY,- 5 , - 19,- 20,+marl ,+mar2 46,XX 46,XX,inv(2)(q22q32),- 7,i(9p/,- 17,

-18 ,+3mar 46,XY,der(3),del(7)(pllp21) 46,XY,del(2)(p14),del(7)(pllp21) 46,XY,-7,+21 45,XY,- 7 46,XX 53 ,X, -X, -8 ,+9 ,+ 11,+ 15,

+ del(18)(q22),+ 19,+ 21,+ 21, +2mar

46,XX 47,XX, + mar 47,XY,+8 45,XY,- 7,del(21)(q21) 46,XX 46,XX,del(11)(q14),del(12)(q?),

18p+ 46,XX,del(11)(q14),del(12)(q?),

18p+ 47,XX,t(1;9)(q11;qll),del(11)

(q14),del(12)(q?),18p + ,+mar 43,XY,- 5 , - 7 , - 11 , -17 ,+mar l 47,XY,+8 46,XY,del(5)(q14q32),

del(13)(q13q31) 46,XX,del(7)(p14) 47,XX,+9 46,XY 46,XY 48,XX,+8,+mar1 50,XX,÷ 1,del(5)(q12q32),

+8,+10,÷11 44,XX,del(5)(q12q23),

- 12,- 13 , -17 ,+mar l 46,XX 46,XX,del(13)(q13q21) 46,XX 46,XX,del(5)(q23q32),

inv(12)(p12q23) 46,XX 46,XX,del(13)(q13q21)

235

Percent b

100 2o 8o 2o 8O 4o 6O 22 55

10o

5O 50 76 22

4O 4O 36 64 8O 2O

66 13

100 100 100 lO0

73

26

84 100 lO0

100 100

93 100 10o 100

100

30 70 45 45

83 16

236

Table 2 Continued

Pat ient Date Sample Cul ture (hr) Karyotype Percent ~

52* 4;80 PB 48 47,XY,del(5)(q14q32),+ 9. 100 del(11}(q21),del(13)(ql 3q31 )

53* 2 7 7 BM 48 46,XX,t(6;22)(q27;qll) , 2 1 , + m a r l 50 46.XX,t(3q ;3q +),t(6;22)(q27;q11), 50

7. -. 21,÷ m a r l , + mar

54 4/82 PB 48 45,XY. 7 100

55 12,'79 BM 48 46 ,XY,-6 , 20 ,+2mar 100

56 7/81 BM 48 46,XX 100

57 4,'84 BM/PB 48 46.XX 100 58 4/83 PB 48 45,XX,del(3q), 7 IO0

59 10/81 BM 72 46,XX 93

60 10/86 BM 48 46,XX 100

61 6/83 BM 48 46,XX 100

62 4,'84 BM 48 46,XX 93 63 10/82 PB 48 46,XX,del(5)(q14q32),t(6:?)(p22;?), 100

del(20)(q11)

64 4:85 BM 48 46.XX 50 47,XX,+8 50

65 12781 PB 48 45.XX,t(3;15][q11:q11). 88 del(5)(q14q32].del(7)(q31),

21 .+f

66 !)/85 BM 48 46,XY,-- 5.5q + ,del(10](q23q25], 70 dH(13)(q12q21) ,~mar

46.XY 3O

67 4/87 BM 24 44,XY.del(4)(q22q 34), 80 del(5)(q12q32}, 12,

t(12:21)(q11;q22), 17,--- 22,

+ mar l

68 3 8 6 PB 48 44,XY,del(5}[q23q32). 16, 100 t[7:15:16)(q11:q11:q11),- 18,

l[12:18)(p12;ql 1)

69 1 0 8 6 BM 48 46,XY.t(3;6){p11:p24},d{~,r(4}, 100 7,9p +.dr!r( 19}, e lnar

70 2,'79 BM 48 45,XY 30 46,XY. 7 , + l n a r l 40

45,XY, 7, 9 , + m a r l 30

71" 1/86 BM 24 46,XX, 3 , - 5,+ der(5).t(5;?)(q13;?], 100 der(6p), - 19, + der(19), t{l l :19)(q13;p13}

72 11:85 BM 48 44.XY, 3, 5, 12 ,+ t ie r (12) . -15 , 100 de, l (17](p12},+marl

73 2/78 PB 48 46,X, Y,t(1;4)(p31;p13), 3 , - 5 , 7, 100 der{9q),del(12)(p12), t(12:?}{q24:7), 10, 17 , -18, + 6mar

74* 4/8(5 BM 24 46,XY 50 46,X. Y, 7 , + 8 . - 1 3 , 50

'del(5)(q14q34),del(6)(p22), inv(121(p12q23),del( l 7)(p11),

2mar

75 4/82 PB/BM 48 46,XY 60 46,XY,del(3)(q14q22} 40

76* 4/76 BM/PB 48 46,XY,t(3;16)"(q11;p11), 100 t{9:10)(?p24:p 12),t(4;5)(p13:q14)

* Included in previous publications,

" Family translocation. ~' Does not include ~ells with randmn abnormalities.

2 3 7

+

~1 2 3 4

.•11 12' 13 14 15 Ill 17 111 19 20 ~'1 22 x y 1 2 4 6 7 1 I0 I I 1 l l 3 14 15 15 1 / l l I t ZO ZI 17 x Yl

Figure 1 Numerical (left) and structural (right) aberrations in 58 patients with s-MDS and s-ANLL.

0,8

Q8

0,4

0,2

Figure 2 Survival in patients with normal karyotype (A/, monosomy 7 as sole anomaly (B), and complex karyotype (C).

I J ) ' - - A

A ~ _ _ a . 8--,E-C I

C--C C-C

C ?

13 C

0- . . . . . . . 5 . . . . . . . -1~) . . . . . . . fS- . . . . . . } 0 . . . . . . . 2'6- . . . . . . 3 0 . . . . . . -~5 - . . . . . . - 40 ( m o n t h s )

238 A. Iurlo et al.

o o

÷ ÷ +

0 0 0

x x x x

÷ ÷ ÷

o

÷

x x x

Figure 3 Chromosomes involved m recurring rearrangements in s-MDS-ANLL. Data from the literature (reference between brackets), x :[20]; ©:[1]; + :[3]; ~:[2]; :[21]; • :[22]; * :[11].

DISCUSSION

Our 76 cases wi th s-ANLL and s-MDS belong to a group that was very heterogeneous with regard to the pr imary condit ion. Nevertheless, we can confirm all impor tant c l inical and hematologic findings repor ted in other big series such as sex and age d is t r ibut ion and t ime of appearance [1-2, 9-12]. A large number of cases repor ted in this paper represent pat ients treated for mul t ip le myeloma, where the risk of deve loping an acute leukemia was calculated to be 14% when melpha lan was admin i s te red for more than 2 years [13] or with total critical dose of melpha lan of about 700 mg [14]. In agreement wi th previous reports, the most common cytogenetic anomaly found in this large series of patients was monosomy 7 [15]. In the present series we also inc luded four patients wi thout history of chemotherapy and/or rad io therapy but who deve loped a secondary blood disorder after toxic exposure. One of these pat ients (case 73) is par t icular ly interest ing because only a few cases of secondary leukemia after thorotrast have been reported in the literature. This radiographic contrast med ium seems to produce an injury to mul t ipotent stem cells, leading to the appearance of marker chromosomes after a long t ime interval (ranging from 16 to 45 years) [16]. Our case deve loped a myelodysplas t ic syndrome after 29 years, fo l lowed by an acute leukemia classified as M6. Similarly, most Japanese cases who deve loped s-ANLL after adminis t ra t ion of thorotrast were diagnosed as having an acute e ry thro leukemia [17].

With regard to morphologic aspects, the erythroid series appeared normal in only two cases, whi le megakaryocytes were dysplast ic in all cases but one. The most frequent mye lodysp las t i c features, involving one or all series, were represented by megaloblastosis in the red cell series; degranulat ion, hypersegmentat ion, and pseudo-Pelger anomaly in the granulocytic series; and micromegakaryocytes and megaloblastosis in the megakaryocyt ic series. All these observations are in good agreement wi th the definit ion of secondary hematologic tumor as a tr i l ineage bone marrow disorder [18, 19].

Al though c l in ica l ly no new elements emerged from our study, at tention should be drawn to some of the chromosomal results. Cytogenetic investigations showed a high propor t ion of chromosome abnormali t ies , 58 out of 76 cases (76.3%). This percentage was higher in pat ients wi th an antecedent history of mul t ip le myeloma or macroglob- u l inemia (92%) and myeloprol i fera t ive disorder (82%) than in the pat ients wi th previous breast cancer (40%). Interestingly, a l l secondary hematologic disorders appear ing after three other solid tumors as pr imary neoplas ia showed an abnormal karyotype.

Looking at a large series of chromosome studies publ i shed in the l i terature [1-3,

Therapy-re la ted Leukemia and MDS 239

11, 20-22] , chromosomes 1, 3, 4, 5, 7, 8, 12, 14, 16, 17, 18, 21, and 22, especial ly nonrandomly showed structural and numerica l anomalies (Fig. 3). An overview of all s tructural and numer ica l changes in our cases is given in Figure 1.

Loss of chromosome 7 was the most common finding (34.4% of abnormal cases), whi le this chromosome had structural rearrangement in only 11.9% of the cases. Interest ingly, the hypothes is of a correlat ion between monosomy 7 and 5 with a previous chemotherapy [23] seems to be confirmed, as we did not observe loss of chromosome 7 in cases who received only radiotherapy. Chromosome 5 was more frequently involved in s tructural (27.5%) than in numerical aberrations (17.2%).

A previous ly proposed associat ion between 5 q - and radiotherapy as the only t reatment [23] could not be found in our study. Patients with 5 q - represented a heterogeneous group (chemotherapy, two cases; RT, three cases; chemotherapy and RT, four cases).

Concerning possible correlat ions between karyotype and antecedent disease, monosomy 5 was more frequently present in nonhematologic diseases, whi le monosomy 7 was observed in all types of malignancies, al though less frequently in pat ients with previous breast cancer or po lycythemia vera. Final ly the occurrence of a 5 q - anomaly was independen t of the nature of the preceding neoplasia , i.e., hematologic disorders or solid tumors.

The third chromosome most frequently involved in numerical and structural aberrat ions was chromosome 3, observed in 18 out of 58 abnormal cases. The abnormal i t ies inc luded structural rearrangements of the long arm in eight cases, of the short arm in three cases, and monosomy in six cases. The involvement of chromosome 3 may be observed in de novo ANLL [24] as well as in secondary MDSoANLL [20, 21]. Structural abnormali t ies of chromosome 3 involving breakpoints near bands q21 have been reported in de novo ANLL associated with high platelet counts and morphologica l ly abnormal megakaryocytes in bone marrow. These hematologic findings were not present in our two cases, as well as in a series of secondary leukemia repor ted by Whang-Peng [20]. Interestingly, one of our two pat ients showed a t(3;8)(q26;q23). Similar breakpoints were recent ly observed by Mertens et el. [25] in a t(3;8)(q26;q24) in one patient wi th MDS and occupat ional exposure.

Chromosome 12 showing a dele t ion involving the short arm was found in seven cases (12% of abnormal cases) in our series. Several studies have been previously publ i shed on the associat ion of a 1 2 p - rearrangement with secondary MDSoANLL [26-28]. Abnormal chromosome 17 was present only in eight cases, none of them with a his tory of previous toxic exposure, as observed by Benitez et el. [1]. Chromosome 21 was involved in numerica l aberrations; three cases showed a loss and three a gain. We observed only two cases with a structural rearrangement on 21q, as repor ted by Pedersen-Bjergaard [22]. In our series seven out of 58 abnormal cases showed a gain of chromosome 8. This aberrat ion is one of the most common numer ica l changes in de novo hematologic tumors, of both lymphoid and myelo id type [29].

All these data clear ly show that in addi t ion to total or part ial losses of chromo- somes 5 and 7, which appear to be highly specific, the frequency and type of the other nonrandom chromosome changes are also important . Al though a certain var iabi l i ty wi th regard to the chromosomes involved and the nature of the chromosome changes is observed, chromosomes 3, 8, 9, 12, 17, and 21 are obviously more involved than others, as i l lustrated in Figures 2 and 3. These observations should be considered if one wants to unders tand the pathogenet ic mechanisms of secondary leukemias and MDS.

240 A. Iur lo et al.

This work was supported by the Inter-University Network for Fundamental Research sponsored by the Belgian government (1987-1991). A. I. is a fellow of the Associazione Italiana per la Ricerca sul Cancro.

REFERENCES

1. Benitez J, Carbonell F, Ferro T, Prieto F, Sanchez Fayos J (1986): Cytogenetic studies in 18 patients with secondary blood disorders. Cancer Genet Cytogenet 22:309-317.

2. Groupe Fran~:ais de Cytogdn6tique H~matologique (1984): Chromosome analysis of 63 cases of secondary nonlymphoid blood disorders. A cooperative study. Cancer Genet Cytogenet 12:95-104.

3. Le Beau MM, Albain KS, Larson RA, Vardiman JW, Davis EM, Blough RR, Golomb HM, Rowlev JD (1986): Clinical and cytogenetic correlations in 63 patients with therapy-related myelodysplastic syndromes and acute nonlymphocytic leukemia: Further evidence for characteristic abnormalities of chromosomes no. 5 and 7. Clin Oncol 4:325-345.

4. Bennett J, Catovsky D, Daniel MT, Flandrin G, Galton DAG, Gralnick HR, Sultan C. The French-Amer ican-Br i t i sh Cooperative Group (1976): Proposals for the classification of acute leukemias. Br l Haematol 33:451-458.

5. Bennett JM, Catovsky D. Daniel MT, Flandrin G, Galton DAG, Gralnick HR, Sultan C. The French-Amer ican-Br i t i sh (FAB) Cooperative Group (1982): Proposals for the classification of the myelodysplastic syndromes. Br J Haematol 51:189-199.

6. Bennett JM, Catovsky D, Daniels MT, Flandrin G, Galton DAG, Gralnick HR, Sultan C (1985): Proposed revised criteria for the classification of acute myeloid leukemia. Ann Intern Med 103:626-629.

7. ISCN (1985). An International System for Human Cytogenetic Nomenclature, Harnden DG, Klinger HP (eds); published in collaboration with Cytogenet Cell Genet (Karger, Basel, 1985); also in Birth Defects: Original Article Series, Vol. 21, No. 1 (March of Dimes Birth Defects Foundation, New York, 1985).

8. F1WCL (First International Workshop on Chromosomes in Leukemia) (1978): Chromosomes in acute nonlymphocyt ic leukemia. Br J Haematol 39, 311-316.

9. Berger R, Bernheim A, Daniel MT, Valensi F, Flandrin G (1981): Leuc~mies "induites." Aspects cytog~ndtique et cytologique. Comparaison avec des leuc~mies primitives. Nouv Rev Fr Hematol 23:275-284.

10. Levine EG, Bloomfield CD (1986): Secondary myelodysplastic syndromes and leukemias. Clin Haematol 15:1037-1080.

11. Pedersen-Bjergaard J, Philip P, Pedersen NT, Hou-Jensen K, Svejgaard A, Jensen G, Nissen NI (1984): Acute nonlymphocyt ic leukemia, preleukemia and acute myeloproliferative syndrome secondary to treatment of other malignant diseases. II. Bone marrow cytology, cytogenetics, results of HLA typing, response to antileukemic chemotherapy and survival in a total series of 55 patients. Cancer 54:452-462.

12. Rowley JD, Golomb HM, Vardiman JW (1981): Nonrandom chromosome abnormalities in acute leukemia and dysmyelopoietic syndromes in patients with previously treated malignant disease. Blood 58:759-767.

13. Wahlin A, Roos G, Rudolphi O, Holm J (1982): Melphalan-related leukemia in multiple myeloma. Acta Med Scand 211:203-208.

14. Kantarjian HM and Keating MJ (1987): Therapy-related leukemia and myelodysplastic syndrome. Semin Oncol 14:435-443.

15. Dewald GW, Kyle RA, Hicks GA, Greipp PR (1985): The clinical significance of cytogenetic studies in 100 patients with multiple my.eloma, plasma cell leukemia, or amyloidosis. Blood 66:380-390.

16. Sadamori N, Miyajima J, Okajima S, Shima M, Yano M, Koga M, Kawamoto M, Fujii H, Mori T, Ichimaru M (1987]: Japanese patients with leukemia following the use of thorotrast including patient with marked chromosomal rearrangements. Acta Haematologica 77:11- 14.

17. Kamiyama R, Ishikawa Y, Hatakeyama S, Mori T, Sugiyama H (1988): Clinicopathological study of hematological disorders after thorotrast administration in Japan. Blut 56:153-160.

T h e r a p y - r e l a t e d L e u k e m i a a n d MDS 241

18. Michels SD, McKenna RW, Arthur DC, Brunning RD (1985): Therapy-related acute myeloid leukemia and myelodysplastic syndrome: A clinical and morphological study of 65 cases. Blood 65:1364-1372.

19. Vardiman JW, Coelho A, Golomb HM, Rowley J (1983): Morphological and cytochemical observations on the overt leukemic phase of therapy-related leukemia. Am J Clin Pharmacol 79:525-530.

20. Whang-Peng J, Young RC, Lee EC, Longo DL, Schechter GP, De Vita VT (19881: Cytogenetic studies in patients with secondary leukemia/dysmyelopoietic syndrome after different treatment modalities. Blood 71:403-414.

21. Sandberg AA, Abe S, Kowalczyk JR, Zedgenidze A, Takeuchi J, Kakati S (1982): Chromo- somes and causation of human cancer and leukemia. L. Cytogenetics of leukemias complicating other diseases. Cancer Genet Cytogenet 7:95-136.

22. Pedersen-Bjergaard J, Philip P (1987): Cytogenetic characteristics of therapy-related acute nonlymphocyt ic leukemia, preleukaemia and acute myeloproliferative syndrome: cor- relation with clinical data for 61 consecutive cases. Br J Haematol 66:199-207.

23. Bloomfield CD (1986): Chromosome abnormalities in secondary myelodysplastic syn- dromes. Scand J Haematol 36(Suppl 45):82-90.

24. Bernstein R, Pinto MR, Behr A, Mendelow B (1982): Chromosome 3 abnormalities in acute nonlymphocyt ic leukemia (ANLL) with abnormal thrombopoiesis. Reports of the patients with a "new" inversion anomaly and a further case of homologous translocation. Blood 60:613-617.

25. Mertens F, Johansson B, Billstr6m R, Engquist L, Mitelman F, (1987): A case of myelo- dysplastic syndrome with high platelet counts and t(3;8)(q26;q24). Cancer Genet Cytogenet 27:1-4.

26. Berger R, Bernheim A, Le Coniat M, Vecchione D, Pacot A, Daniel MT. Flandrin G (1986): Abnormalit ies of short arm of chromosome 12 in acute nonlymphocytic leukemia and dysmyelopoietic syndrome. Cancer Genet Cytogenet 19:281-289.

27. Web HJ, Hossfeld DK (1986): 1 2 p - chromosome in patients with acute myelocytic leukemia or myelodysplastic syndromes following exposure to mutagenic agents {letter). Cancer Genet Cytogenet 19:355-356.

28. Wilmoth D, Feder M, Finan J, Nowell PC (1985): Preleukemia and leukemia with 12p and 19q+ chromosome alterations following alkeran therapy. Cancer Genet Cytogenet 15:95- 98.

29. Mitelman F (1988): Catalog of Chromosome Aberrations in Cancer, 3rd Ed. Alan R. Liss, New York.