Possible association between adult T-cell leukemia/lymphoma and acute myeloid leukemia

An Unusually Short Latent Period of Therapy-Related Myeloid Neoplasm Harboring a Rare MLL-EP300 Rearrangement: Case Report and Literature Review

Therapy-related myeloid neoplasm (t-MN) is a late and lethal complication induced by chemotherapy and/or radiation therapy. Hematological malignancy is one of the most common primary diseases in patients with t-MN. However, the occurrence of t-MN in adult T-cell leukemia/lymphoma (ATL) patients is rarely reported, possibly due to the dismal prognosis of ATL per se. Here, we report a 62-year-old female who developed t-MN only three months after the completion of conventional chemotherapy and anti-CCR4 antibody for ATL acute type. The patient presented with persistent fever and monocytosis without any evidence of infectious diseases. Bone marrow examinations revealed chronic myelomonocytic leukemia-like disease with a chromosomal translocation of t(11;22)(q23;q13) as a solo cytogenetic abnormality, resulting in the diagnosis of t-MN. Next-generation sequencing analysis identified a rare chimeric transcript, MLL-EP300, without any additional somatic mutations. Although the patient underwent allogenic hematopoietic stem cell transplantation, she died of viral encephalomyelitis at 7 months after diagnosis of t-MN. Since recent therapeutic advances have extended the survival of patients with ATL, further evaluation of the long-term risks of developing t-MN in these patients is warranted.

Analyses and treatment of simultaneous bi-lineage malignancies of myeloid leukemia and lymphoma: Two case reports and a literature review

The present study reports two cases of concurrently diagnosed T-lymphoblastic lymphoma (T-LBL) and chronic myeloid leukemia (CML). The literature review revealed that myeloid leukemia may appear secondary to Hodgkin lymphoma or non-Hodgkin lymphoma. However, simultaneous bi-lineage hematologic malignancies are rarely seen and the prognosis is worse than single lineage lymphoma or myeloid leukemia. There were no standard therapies. All simultaneous bi-lineage malignancies of myeloid leukemia and lymphoma reported in Pubmed were combined with the present two cases, to analyses its pathogenesis, features and treatment. It was concluded that the prognosis of bi-lineage hematologic malignancies was poor, however allogeneic hematopoietic stem cell transplantation could improve survival (P=0.033).

Therapy-related Acute Myeloid Leukemia after the Long-term Administration of Low-dose Etoposide for Chronic-type Adult T-cell Leukemia-lymphoma: A Case Report and Literature Review

A 61-year-old woman with chronic-type adult T-cell leukemia-lymphoma (ATL) had been taking low-dose oral etoposide for progressive lymphocytosis. After taking this for 3.5 years, she was diagnosed with therapy-related acute myeloid leukemia (t-AML), with a chromosomal translocation of t (6:11) (q27; q23). She thus received remission induction therapy, consolidation therapy, and allogeneic hematopoietic stem cell transplantation. Although both t-AML and ATL were in remissive states, she died of a therapy-related infection within 1 year. We reviewed 12 reported cases of AML complicating ATL to better characterize this unusual disease. We should therefore include t-AML in the differential diagnosis when administering low-dose etoposide for ATL over a long period of time.

Acute Myeloid Leukemia Diagnosed 5 Years after Adult T-Cell Leukemia/Lymphoma

A case of secondary acute myeloid leukemia (AML) was identified following adult T-cell leukemia/lymphoma (ATL), for which combination chemotherapy had been administered, including epipodophyllotoxin, anthracycline, and alkylating agents. AML with maturation was diagnosed by the cytological findings, cell surface markers, and chromosomal abnormalities. We previously reported two cases of AML accompanied by ATL. In this case of AML after chemotherapy for ATL, we considered that the AML was probably associated with previous chemotherapy for ATL. Although the ATL remained in remission, the therapy-related AML with complex chromosomal abnormalities proved resistant to chemotherapy, and the patient died from complications associated with AML.

Human T-lymphotropic virus type I infection and idiopathic thrombocytopnic purpura

Human T-lymphotropic virus type I (HTLV-I) is the causative agent in adult T-cell leukemia and HTLV-I associated myelopathy. Some other diseases such as uveitis, chronic thyroiditis, Sjögren syndrome, arthritis, acute myeloid leukemia and myelodysplastic syndrome may be also associated with HTLV-I. Several case reports have suggested the possible combination of idiopathic thrombocytopenic purpura (ITP) and HTLV-I infection. In these studies and from our current report, we found 17 patients (22.1%) with HTLV-I infection among 77 ITP patients. The prevalence of HTLV-I infection among ITP patients was higher than that of healthy volunteers (5 approximately 10%). The ITP patients with HTLV-I infection were older than the patients without HTLV-I infection, and the ITP patients with HTLV-I infection had poor response to prednisolone therapy. Among 17 ITP patients with HTLV-I infection, 9 patients received prednisolone therapy. Although most patients had transient increase of platelet counts, only two of them had partial responses (PR) at the last observation date. Five patients underwent splenectomy, and four of them had complete responses (CR) and the remaining patient had a (PR). Four patients received eradication of Helicobactor pylori (H. pylori) infection, and all patients had CRs. Therefore, the ITP patients with HTLV-I infection should receive eradication therapy in the case of H. pylori infection as the first step of therapy and the splenectomy should be considered, if there is no response to conventional therapy. Human immunodeficiency virus (HIV) causes thrombocytopenia in 10% of patients with active HIV disease. The etiologies of HIV thrombocytopenia are considered as follows, the escalated destruction of platelets by the immune system, damage to megakaryocytes by HIV infection and the inhibition of thrombopoiesis by some anti-viral drugs. In the case of ITP patients with HTLV-I infection, the main etiology may be the increased destruction of platelets by immune system. The proviral load and the integration pattern of HTLV-I should be examined to clarify the stage of HTLV-I infection. The possibility of infection of the megakaryocytes by HTLV-I should be also examined for etiological approach.

High prevalence of human T-lymphotropic virus type I carriers among patients with myelodysplastic syndrome refractory anemia with excess of blasts (RAEB), RAEB in transformation and acute promyelocytic leukemia

We examined human T-lymphotropic virus type I (HTLV-I) infection among patients with myelodysplastic syndrome (MDS), refractory anemia with excess of blasts (RAEB)/RAEB in transformation (RAEBt) and acute myelogenous leukemia (AML). The study population consisted of 151 patients: 46 with MDS RAEB/RAEBt and 105 with AML (M1, n = 15; M2, n = 39; M3, n = 18; M4, n = 19; M5, n = 9; M6, n = 3; M7, n = 2). As a reference, we examined 92 patients with refractory anemia (RA) and 405 patients with cardiovascular diseases (CVD). Thirteen patients with RAEB/RAEBt (28.3%), 11 with AML (11.6%), 27 with RA (29.3%), and 45 with CVD (11.0%) were positive for HTLV-I. Seven AML patients with HTLV-I infection had M3 acute promyelocytic leukemia (APL). The prevalences of HTLV-I infection among patients with RAEB/RAEBt (P < 0.001), APL (P = 0.001), and RA (P < 0.001) were significantly higher than that in patients with CVD. The prevalences of HTLV-I infection were still significantly higher in patients with RAEB/RAEBt (P = 0.007), APL (P = 0.017) and RA (P < 0.001) than in those with CVD matched by sex and age. Platelet counts and survival times of RAEB/RAEBt patients with infection were significantly lower than those of patients without infection.

T-cell acute lymphoblastic leukemia relapsing as acute myelogenous leukemia

We present the unusual case of a 16-year-old girl with T-cell acute lymphoblastic leukemia (ALL) with an early thymocyte immunophenotype without myeloid markers, who after 13 months of complete hematological remission relapsed as acute myelogenous leukemia (AML) with minimal differentiation and died of her disease. Whether the AML represented a relapse with lineage switch of the original immature T-cell clone or a new secondary malignancy, could not be proven due to the absence of molecular or clonal markers. This report suggests that a subset of CD7+ T-cell leukemias without mature T-cell antigens (CD4-, CD8-) are minimally differentiated and can relapse as AML.

T-cell lymphoblastic leukemia/lymphoma syndrome with eosinophilia and acute myeloid leukemia

This case represents an example of an unusual T-cell lymphoblastic leukemia/lymphoma syndrome associated with eosinophilia and myeloid malignancy in a young boy. This case is one of only five reported "leukemic" variants of the disease and demonstrates the importance of considering this poor prognostic diagnosis in pediatric acute lymphoblastic leukemia. This case also illustrates the importance of an interactive multidisciplinary approach to the laboratory evaluation of a leukemia patient.

Poor response to prednisolone of idiopathic thrombocytopenia with human T-lymphotropic virus type I infection

We describe the unique clinical characteristics of patients with idiopathic thrombocytopenic purpura (ITP) who are infected by human T-lymphotropic virus type I (HTLV-I). Thirty-seven patients with ITP were examined in the present study: 10 patients had HTLV-I infection, and the remaining 27 did not. The mean age of the group with HTLV-I infection was significantly older than that of the group without infection (57.8 +/- 14.0 and 42.4 +/- 20.1, P = 0.022). The difference in mean platelet counts at diagnosis between the two groups was not significant, 29 x 10(9)/L and 21 x 10(9)/L, respectively. The levels of platelet associated IgG, red blood cell count, white blood cell count, bone marrow cell count, and megakaryocyte count did not show any significant difference. Nine patients in the group with HTLV-I infection were treated with prednisolone (1 mg/kg, daily oral). Only 3 of them responded to the therapy (one complete response [CR] and two partial responses [PR]). However, 17 of 22 patients not infected with HTLV-I were treated with prednisolone successfully: 14 patients achieved CR, and 3 patients achieved PR. There was a significant difference in response to prednisolone between the two groups (P = 0.034). Two patients with the infection and one patient without the infection achieved CR with splenectomy. These results suggest that HTLV-I infection may cause immune thrombocytopenia by a different mechanism than classical ITP; HTLV-I may modify the clinical features of ITP through an unknown immune pathway.

Therapy-related myelodysplastic syndrome in a case of cutaneous adult T-cell lymphoma

We report a case of therapy-related myelodysplastic syndrome (t-MDS) in adult T-cell lymphoma. A 69-year-old man suffered from cutaneous adult T-cell lymphoma, which was treated with radiation to the skin and combination chemotherapy of CHOP-V-MMV and VEPA-B. After 14 months of these therapies, anemia and thrombocytopenia appeared, and bone marrow aspiration smears showed immature myeloblasts, dysplastic erythroblasts, and micromegakaryocytes. Therapy-related MDS of refractory anemia with an excess of blasts was diagnosed. Cytogenetic study of the bone marrow cells showed 5q- and additional abnormalities. Rearrangement of the MLL gene was observed in the bone marrow cells. Mutations of N-ras codons at 12,13, and 61, p53 tumor suppressor gene, and monoclonal integration of human T-lymphotrophic virus -1 provirus DNA were not observed in the bone marrow cells. The patient died of pneumonia 21 months after diagnosis of cutaneous adult T-cell lymphoma.

Myelodysplastic syndrome in a patient with adult T-cell leukaemia

A 53-year-old female who developed myelodysplastic syndrome (MDS) after chemotherapy for adult T-cell leukaemia (ATL) is described. The latent period of therapy-related MDS (t-MDS) from the time of diagnosis of ATL was approximately 35 months. Cytogenetic analysis of the bone marrow cells at the time of diagnosis of t-MDS revealed a clonal abnormality; 46,XX,add(7)(p13), der(17)t(3;17)(p11;p13). Although monoclonal integration of human T lymphotropic virus type I (HTLV-I) proviral DNA was detected in the peripheral blood lymphocytes at ATL diagnosis, bone marrow cells at t-MDS diagnosis did not show monoclonal integration of HTLV-I. To our knowledge, this is the first report of t-MDS associated with ATL.