t(8;21)(q22;q22) is the most frequently observed karyotypic abnormality associated with acute myeloid leukemia (AML), especially in FAB M2. Clinically, this type of AML often shows eosinophilia and has a high complete remission rate with conventional chemotherapy. t(8;21) AML is also frequently associated with additional karyotypic aberrations, such as a loss of the sex chromosome; however, it is unclear whether these aberrations change the biological and clinical characteristics of t(8;21) AML. To investigate this issue, 94 patients with t(8;21) AML were categorized according to their additional karyotypic aberrations, which were detected in more than three cases, and then morphologic features, phenotypes, expression of cytokine receptors, and clinical features were compared to t(8;21) AML without other additional aberrant karyotypes. t(8;21) AML with loss of the sex chromosome and abnormality of chromosome 9 were found in 27 cases (29.3%) and 10 cases (10.6%), respectively; however, no differences were observed from the t(8;21) AML without other additional karyotypes in terms of morphological and phenotypic features. There was also no significant difference in the clinical outcome among these three groups. On the other hand, trisomy 4 was found in three cases (3.2%) and these cells showed low expressions of CD19 (P=0.06) and IL-7 receptor (P=0.05), and high expressions of CD33 (P=0.13), CD18 (P=0.03), and CD56 (P=0.03) when compared to t(8;21) AML without additional karyotypes. Moreover, all three t(8;21) AML cases with trisomy 4 did not show eosinophilia in their bone marrow and died within 2.4 years. These observations suggest that additional karyotypic aberration, t(8;21) with trisomy 4 is rare, but it may constitute a distinctive subtype of t(8;21) AML.
Acute leukemia with a particular chromosomal abnormality often shows unique biological and clinical characteristics. In these cases, the translocation (8;21)(q22;q22) (t(8;21)) is one of the most common karyotypic abnormalities in acute myeloid leukemia (AML) and is closely associated with the AML-M2 subtype (French–American–British Classification; FAB1,2) (18–40%).3 This type of AML has a high complete remission (CR) rate with standard chemotherapy, and a prolonged survival when sequential high-dose cytarabine is administered.4,5,6,7 Previous reports including ours have demonstrated that t(8;21)AML shows high levels of CD34 and DR expression, with a prevalent positivity for CD19 and CD56 surface markers and a low expression of CD33 and CD7 when compared to AML with normal or other aberrant karyotypes, and eosinophilia is also often observed in t(8;21) AML.8,9,10,11,12,13,14,15 Cytogenetically, the t(8;21) AML is frequently associated with a loss of the sex chromosome Y in males and inactive X in females;3 3.4% of the cases are variant translocations.16 However, the influence of these variant translocations or additional chromosomal abnormalities on the characteristics of t(8;21) AML is still unclear.
To investigate whether additional chromosomal abnormalities may change the biological and clinical characteristics of t(8;21) AML, a large number of patients with t(8;21) AML (94 cases) were categorized into subgroups according to their additional karyotypic aberrations and then morphological features, phenotypes, expression of cytokine receptors, and clinical features in these groups were analyzed.
Materials and methods
From 1987 to 2001, 94 Japanese adult patients (age 15 years or older) newly diagnosed with t(8;21) AML were consecutively registered from seven collaborating hospitals after obtaining informed consent. All patients have been prospectively enrolled in 1 of the 5 Japan multicenter trials. Induction therapies were as follows: JALSG-AML87, behenoyl cytarabine (BHAC) or cytarabine (Ara-C) plus daunomycin (DNR) and 6-mercaptopurine (6MP);17,18 JALSG-AML92, BHAC, DNR, and 6MP with or without etoposide (ETP);19 JALSG-AML95, Ara-C, and DNR;20 JALSG-AML97, Ara-C, and idarubicin hydrochloride (IDR);21,22 B-DOMP, DNR, VCR, BHAC, 6-MP, PDN with or without ETP. High- or intermediate-dose Ara-C as postremission therapy was not used on any patients. CR was defined as the presence of less than 5% blast cells in bone marrow (BM) aspirate after induction therapy.
Flow cytometric analysis of surface antigens
Leukemic BM or peripheral blood (PB) samples were collected. Mononuclear cells (MNC) were separated by Ficoll–Hypaque density gradient centrifugation. In all cases, over 90% of the isolated cells had leukemic cell-like morphology. Immunostaining for leukemic cells was carried out as described previously.23 CD19, CD20 (Becton Dickinson Immunocytometry Systems, San Jose, CA, USA) and CD10 (DAKO, Glostrup, Denmark) were used as B-cell markers. CD7, CD56, CD18, and CD25, all from Becton Dickinson Immunocytometry Systems, were used as T- or NK-cell markers. CD14, CD11b, CD11c, CD33, CD34, CD38 (Becton Dickinson Immunocytometry Systems), and CD13 (CALTAG Laboratories, Burlingame, CA, USA) were used as myeloid- or stem-cell markers. Flow cytometric analysis of cytokine receptors was performed using the following antibodies; mouse monoclonal antibodies against human IL-3 receptor α chain (IL-3Rα), c-kit, and granulocyte colony-stimulating factor (G-CSF) receptor (G-CSFR) were purchased from PharMingen (San Diego, CA, USA). Mouse monoclonal antibodies against human IL-5Rα and IL-7Rα were obtained from Immunotech (Marseille, France), mouse monoclonal antibody against human granulocyte/macrophage colony-stimulating factor (GM-CSF) receptor α chain (GM-CSFRα) was purchased from Genzyme (Cambridge, MA, USA). The expression of cytoplasmic Bcl-2 (DAKO) in leukemic cells was studied as described previously.13 For evaluation of the intensity of the cytokine receptors and Bcl-2 expressions, the assessment was performed by relative fluorescence intensity (RFI); RFI is the mean number of fluorescence intensity (FI) in log scale of monoclonal antibody-added sample – the mean number of FI in log scale of the isotype control.13
Cytogenetic analysis and interphase fluorescence in situ hybridization (FISH) of chromosome 4
A chromosomal analysis (G-banding) was performed as diagnosis on a 24 h in vitro BM cell culture. Interphase FISH of the chromosome 4 study was performed as previously reported.24 The cells of BM MNC from three cases of t(8;21) AML with trisomy 4 were transferred to multicompartmentalized microscope slides (DAKO) and dried by evaporation. The slides were dehydrated in ascending concentrations of alcohol, denatured, and dehydrated again. The cells were then probed using a mixture of chromosome 4 labeled with Spectrum Orange (Vysis, Downers Grove, IL, USA) and stained with DAPI (Vysis). At least 300 cells were observed in each sample.
Detection of AML1/ETO fusion gene by reverse transcriptase-polymerase chain reaction (RT-PCR)
RNA was extracted from primary leukemic cells and the expression of AML1/ETO gene was studied using RT-PCR, as described previously.25 PCR was performed for 35 cycles, under the following conditions: 1 min at 94°C for denaturating, 1 min at 57°C for annealing, and 2 min at 72°C for extending. The following oligonucleotide primers were used:26 sense, 5′-IndexTermAGC CAT GAA GAA CCA GG-3′; antisense, 5′-IndexTermAGG CTG TAG GAG AAT GG-3′; β-actin sense, 5′-IndexTermGTG GGG CGC CCC AGG CAC CA-3′; β-actin antisense, 5′-IndexTermGTC CTT AAT GTC ACG CAC GAT TTC-3′. The PCR products were electrophoresed on a 3% agarose gel, in comparison with the molecular-weight ladder (∅174 digested by Hae III) and stained with ethidium bromide for viewing under UV illumination.
The differences between single antigen expressions were evaluated by the Student's t-test using StatView software (SAS Institute, Cary, NC, USA). Patient survival data were analyzed by the Kaplan–Meier method and were compared by means of the log-rank test. Survival was calculated from the first day of induction therapy to death. Patients who underwent bone marrow transplantation (BMT) were censored at the date of BMT.
t(8;21) AML samples and classification by additional chromosomal abnormality
The aim of this study was to investigate whether additional chromosomal abnormality altered the characteristics and clinical features of t(8;21) AML. To investigate this issue, 94 AML cases with t(8;21) were categorized into five groups as follows; Group I (GI, 45 cases) without other karyotypic abnormalities, Group II (GII, 27 cases) with deletion of the sex chromosome, Group III (GIII, three cases) with trisomy 4, Group IV (GIV, 10 cases) with abnormal chromosome 9, and Group V (GV, nine cases) with other chromosomal abnormalities (Tables 1 and 2). The median ages were 49 (range 15–73), 47 (range 16–80), 48 (range 42–62), 45 (range 16–56), and 39 (range 17–63) years in patients of the GI, GII, GIII, GIV, and GV groups, respectively (Table 1).
Morphologic features in t(8;21) AML
According to the FAB classification, five patients were M1, 88 M2, and one M4 (Table 1). As described previously,27,28 patients with t(8;21) AML typically present with FAB M2 morphology, with a minority of cases presenting M1 or M4. Although eosinophilia is one of the characteristics in morphological features of t(8;21) AML,11,15,27,29 BM smears from three cases of t(8;21) AML with trisomy 4 did not show any eosinophils (Tables 1 and 2 and Figure 1). Andrieu et al showed a well-defined scoring system, called the weighted score (WS), based on the attribution of different weights to define morphological parameters of t(8;21) AML.12 Using their system, leukemic cells of t(8;21) AML with trisomy 4 were scored, and all three cases had morphological features suggestive of a t(8;21) AML except eosinophilia (Table 3 and Figure 1).
Expression of surface antigens on t(8;21) AML
Table 4 and Figure 2 show the median percentage of positive cells, and the range and results of statistical analysis performed by the t-test are illustrated for each antigen. When additional chromosomal abnormality with t(8;21) AML groups (GII, GIII, GIV, and GV) was compared to t(8;21) AML without another aberrant karyotype (GI), differences were found for CD19, CD33, CD18, and CD56 expression on AML cells in GIII. The AML group with trisomy 4 (GIII) showed less expression of CD19 (median 6.3 vs 34.9%, P=0.06). In contrast, CD33 (68.0 vs 27.4%, P=0.13), CD18 (81.5 vs 48.0%, P=0.03), and CD56 (91.0% vs 44.0%, P=0.03) expressions were elevated in GIII patients. In the cytokine receptor expression on t(8;21) AML, IL-7Rα (38.6 vs 65.9, P=0.05) was expressed less on the cells in GIII (Table 5 and Figure 2).
Previous investigations have shown that blasts from AML M2 with t(8;21) display high levels of CD34, and lower CD33 expression, with frequent positivity for CD19 and CD56 surface markers, and an absence of CD7 antigen expression when compared to t(8;21) negative M2 AML.9,12,30 In this study, we demonstrated that t(8;21) AML with trisomy 4 has lower expressions of CD19 and IL-7Rα, and displays higher CD33, CD18, and CD56 expressions.
Clinical features of t(8;21) AML
Clinically, the t(8;21) AML present at diagnosis in 7% of cases of adult de novo AML is generally associated with a high CR rate and prolonged disease-free survival.4,5,6 In our study, the CR rate of t(8;21) AML patients treated with conventional induction therapy was 95.3% and the 5-year survival rate was 52.0% (Table 1 and Figure 3a). Among the subgroups of t(8;21) AML patients, the overall survival was significantly shorter in patients whose cells had trisomy 4 (P<0.05) (Figure 3b).
FISH analysis of chromosome 4
Analysis by interphase FISH using chromosome 4 probe also confirmed that three fluorescent signals were detected in 68, 75, and 80% of BM blastic cells in patients of the GIII-1, GIII-2, and GIII-3, respectively (Figure 4a). Two of those three patients (Cases GIII-2 and GIII-3) were CR after conventional induction chemotherapy and trisomy 4 was not detected in their BM samples using interphase FISH and karyotype analysis (Figure 4b). We could not prove whether erythroid cells were affected by trisomy 4 at the onset, because erythroid cells were less than 5% in their BM samples.
Detection of the AML1/ETO gene on the cells with trisomy 4
The fusion gene of AML1 and ETO is causally related to the occurrence of t(8;21) AML.31,32 On the other hand, it has also been reported that some cases with t(8;21) lack the AML1/ETO fusion gene.33 Therefore, the expression of the AML1/ETO fusion gene was studied in the leukemic cells of t(8;21) AML with trisomy 4 (Cases GIII-1, GIII-2, and GIII-3) and was detected in all three samples (Figure 5). The expression of AML1/ETO fusion gene was also confirmed in other samples of t(8;21) AML with or without additional chromosomal abnormalities (data not shown). Kasumi-1,34 a cell line derived from an AML (M2) patient with t(8;21), was used as a positive control.
In this study, we show that t(8;21) AML with trisomy 4 is very rare since it was found in only three out of 94 cases (3.2%); however, the relevant clinical features of these cases are different from t(8;21) AML. Trisomy 4 as the sole karyotype aberration is an uncommon numerical chromosomal aberration in AML, the majority of cases being diagnosed as FAB M2 or M4.35,36,37 In the cytogenetic analysis of 305 patients with primary AML, two patients with trisomy 4 as the sole karyotype aberration were found (0.6%) and these two cases had a poor prognosis.36 Weber et al summarized 20 AML patients with trisomy 4. According to their study, the CR rate was 61%.36 Keung et al38 also reviewed the literature of acute leukemia with trisomy 4. The mean age was 47.8 years and there were 37 cases of AML, 27 (73%) cases were either M2 or M4 subtypes, three acute lymphoblastic leukemia, one undifferentiated leukemia, one biphenotypic leukemia, and three cases with myelodysplastic syndrome. Of the 28 cases of AML who were treated with induction chemotherapy, the CR rate was 72% and the median survival was 12 months. These observations including our results show that the clinical features of t(8;21) AML with trisomy 4 may be similar to those observed by other authors in patients with AML and trisomy 4 as an isolated change. It has been reported that CD56 expression in t(8;21) AML is associated with a significantly shorter CR duration and survival, and also found to be associated with extramedullary disease.14,39 All three t(8;21) AML with trisomy 4 expressed CD56 and had a poor prognosis; however, extramedullary disease was not found in these cases. Therefore, we cannot explain the relation between CD56 expression and trisomy 4, and further investigation will be necessary. While the development of AML with trisomy 4 secondary to chemo- or radiotherapy has also been suggested,36,40,41,42 our present three cases with trisomy 4 had no history of long-term medication, radiotherapy, or occupational exposure to any toxins.
In conclusion, our data suggest that morphological features, phenotypic findings, and clinical features of t(8;21) AML with trisomy 4 are different from those of t(8;21) AML. Even though trisomy 4 is likely to be a secondary event after the t(8;21) translocation, the presence of this additional numerical aberration may define a distinctive subtype of AML with t(8;21)/AML1/ETO fusion.
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Thanks are due to Drs SI Kageyama, M Masuya, K Ohishi, M Yamaguchi, H Mitani, H Araki, M Sakakura, Y Sugimoto (Second Department of Internal Medicine, Mie University School of Medicine, Mie, Japan); K Kawakami, Y Watanabe (Suzuka Gentral Hospital, Mie, Japan); K Oka (Suzuka Kaisei Hospital, Mie, Japan); T. Sekine (Matsusaka Genaral Hospital, Mie, Japan); K Tsuji, S Tamaki (Yamada Red Cross Hospital, Mie, Japan); T Tsukada, H Kihira (Takeuchi Hospital, Mie, Japan); K, Ikeda (Ise Citizen Hospital, Mie, Japan); M Shikami (The Second Department of Internal Medicine, Aich University School of Medicine, Aich, Japan); I Furuta, M Itou (Shinguu Citizen Hospital); M Nomura (Third Department of Internal Medicine, Kyoto Prefectural University of Medicine); and H Tsutani (First Department of Internal Medicine, Fukui Medical University, Fukui, Japan).
This work was supported by research grants from the Ministry of Education, Culture, Sports, Science, and Technology and from the Ministry of Health, Labour, and Welfare, Tokyo, Japan.
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Nishii, K., Usui, E., Katayama, N. et al. Characteristics of t(8;21) acute myeloid leukemia (AML) with additional chromosomal abnormality: concomitant trisomy 4 may constitute a distinctive subtype of t(8;21) AML. Leukemia 17, 731–737 (2003). https://doi.org/10.1038/sj.leu.2402871
- trisomy 4
- additional karyotypic aberration
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