Acute lymphoblastic leukemia supervening in a case of chronic lymphocytic leukemia after continuous 3-year treatment with chlorambucil

B-lymphoblastic leukemia in a patient with chronic lymphocytic leukemia: Sequential development of biclonal B-cell neoplasms over a 23-year period in a single individual

Chronic lymphocytic leukemia (CLL) is an indolent mature B-cell neoplasm. During a prolonged disease course, a secondary B-cell neoplasm may arise in some patients, the most common example being the clonal evolution of CLL to diffuse large B-cell lymphoma, which is referred to as Richter transformation. Secondary de novo mature B-cell neoplasms arising in a patient with pre-existing CLL have been described; however, B-lymphoblastic leukemia (B-ALL) developing in untreated CLL is rare, and its clonal relationship to the primary neoplasm has been an interesting issue. Herein, we report an unusual case of the sequential development of CLL and B-ALL over a 23-year period in a 64-year-old male. Examination of the peripheral blood smear and bone marrow biopsy demonstrated dual neoplastic populations: small mature lymphocytes consistent with those seen in CLL and a population of blasts that were confirmed to be B-ALL by immunophenotyping. The biclonality of these two B-cell neoplasms was supported by cytogenetic studies. While an intrinsic immunodeficiency in patients with CLL may predispose them to the development of other malignancies, the pathogenesis of this unusual phenomenon remains to be further investigated.

Management of chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia (CLL) is the most common form of adult leukaemia in Western countries. The diagnosis requires mature-appearing lymphocytes in the peripheral blood to >5 x 10(9)/L. The immunophenotype typically includes B cell antigens CD19, CD20 and CD23, low expression of surface immunoglobulin and CD5+, with other T cell antigens absent. Bone marrow biopsy, although not required for diagnosis, must show at least 30% lymphocytes. Cytogenetic abnormalities are frequent in patients with CLL, and may be associated with poor prognosis. Clinically, most patients are asymptomatic at presentation, with incidental lymphadenopathy and/or hepatosplenomegaly in the routine physical examination. Infections by opportunistic pathogens are the major cause of death. Aggressive transformation occurs in 10% of patients with CLL, most commonly prolymphocytic leukaemia (PLL) and Richter's syndrome. PLL de novo must be differentiated from PLL of an aggressive transformation. The incidences of autoimmune diseases and solid or haemopoietic secondary malignancies are increased in patients with CLL. Clinical stage is the strongest prognostic factor in CLL. There is no indication for early intervention. The current recommendation to start treatment includes disease-related symptoms, massive and/or progressive hepatosplenomegaly or lymphadenopathy, increasing bone marrow failure, autoimmune disease, and recurrent infections. Alkylating agents (e.g. chlorambucil) and nucleoside analogues (e.g. fludarabine) are the most active agents for CLL. Fludarabine induces higher response rates, but no improvement in overall survival has been observed. Fludarabine is the drug of choice for the majority of patients with CLL. Chlorambucil may be helpful for elderly patients with poor performance, and for patients who do not tolerate fludarabine. No drug combination is better than single agents. For patients refractory to initial treatment, referral to a clinical trial is the best choice. Other salvage therapy includes retreatment with the same initial agent (chlorambucil or fludarabine) if initial response was observed, or fludarabine for patients refractory to chlorambucil. Promising new approaches include cycle-active agents, nelarabine, biological therapy such as anti-CD52 monoclonal antibody, bone marrow transplantation, including the use of submyeloablative preparative regimens ('minitransplant') to induce graft-versus-leukaemia effect, and gene therapy. Prophylactic antibacterials and intravenous immunoglobulin should not be used routinely during supportive care. Epoetin may be helpful for patients who have anaemia without obvious cause. Assessment of response to therapy in CLL has been updated by the National Cancer Institute Working Group, and these guidelines are used worldwide for clinical trials.

Second malignancies as a consequence of nucleoside analog therapy for chronic lymphoid leukemias

PURPOSE

The nucleoside analogs fludarabine, 2'-deoxycoformycin (DCF), and 2-chlorodeoxyadenosine (CdA), commonly used in the treatment of patients with indolent lymphoid malignancies such as chronic lymphocytic leukemia (CLL) and hairy cell leukemia (HCL), are associated with myelosuppression and profound and prolonged immunosuppression. These complications raise the possibility of an increase in secondary malignancies in patients whose disease already places them at greater risk. The purpose of the present study was to assess the frequency of second tumors in patients with CLL who are treated with fludarabine and in patients with HCL who are treated with DCF and CdA.

PATIENTS AND METHODS

We reviewed the long-term follow-up data for 2,014 patients treated on National Cancer Institute Group C protocols with fludarabine for relapsed and refractory CLL and with DCF and CdA for HCL using a Second Cancer Report. The numbers of observed and expected secondary tumors were compared.

RESULTS

Median follow-up periods for the DCF (n = 409), fludarabine (n = 724), and CdA (n = 979) studies were 6.9, 7.4, and 5.1 years, respectively. The 111 malignancies were most commonly lymphoma (25 patients), prostate (19), lung (15), colorectal (nine), bladder (six), and breast (six), but also CNS, stomach, ovary, head and neck, melanoma, sarcoma, testicular, and myeloid leukemias. Compared with age-adjusted 1994 Surveillance and Epidemiology End-Results rates for the general population, the observed/expected frequencies for DCF, fludarabine, and CdA were 1.43 (95% confidence interval [CI], 0.93 to 2.10), 1.65 (95% CI, 1.04 to 2.47), and 1.50 (95% CI, 1.14 to 1.93), respectively, indicating a significant (at P =.05) increase in risk for patients treated on the latter two protocols compared with a normal population. However, these values are consistent with the increase already associated with these diseases.

CONCLUSION

Despite their immunosuppression, nucleoside analogs can be safely administered to patients with CLL or HCL without a significantly increased risk of secondary malignancies.

Z-138: a new mature B-cell acute lymphoblastic leukemia cell line from a patient with transformed chronic lymphocytic leukemia

We describe a new mature B-cell acute lymphoblastic leukemia (ALL) cell line designated Z-138 that was derived from a patient with chronic lymphocytic leukemia (CLL) whose disease underwent transformation to a rare, aggressive form of mature B-cell ALL. This cell line has an L3 morphology, ultrastructural characteristics of lymphoblasts, B-lineage surface markers and an immunoglobulin heavy-chain gene rearrangement identical to the rearrangement observed in the patient's blasts from whom the cell line was derived. Z-138 cells produce granulocyte-macrophage colony-stimulating factor (GM-CSF) and high levels of granulocyte-CSF (G-CSF), but they do not exhibit a proliferative response to either cytokine. Both the patient's lymphoblasts and Z-138 cells exhibited cytogenetic abnormalities including t(8;14), t(14;18) and a chromosome 11 abnormality similar to the t(11;14) of the parental cells, resulting in marked overexpression of cyclin D1 (BCL-1 (PRAD1)) mRNA in Z-138 cells. Since these karyotypic anomalies have been associated with low grade (t(14;18)), intermediate grade (t(11;14)) and high grade (t(8;14)) lymphomas, their development may be involved in the unusual aggressive transformation of this patient's CLL.

Acute Lymphoblastic Leukemia Occurring in a Case of Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a disease characterized by variable clinical presentation and a prolonged course. However, a small proportion of cases may evolve to more aggressive forms. These include acute leukemic blastic crises of both myeloid and lymphoid types, prolymphocytoid transformation, lymphoma and multiple myeloma. We describe a case of B-CLL treated with chlorambucil, in whom a picture of acute lymphoblastic leukemia of pre-B type developed. The diagnosis of both forms of leukemia is well documented on the basis of morphological, cytochemical and immunological findings. Documentation and investigation of cases of ALL occurring in CLL is of importance to determine whether the transformation represents a clonal evolution of the original CLL or an independent second malignancy in an immunocomprimised patient.

Waldenström's macroglobulinaemia: results of a combined oral treatment in 34 newly diagnosed patients

From February 1978 to September 1987, 34 patients with Waldenström's macroglobulinaemia (WM) were treated using an oral combination consisting of melphalan (6 mg m, days-2 1-7) cyclophosphamide (125 mg m-2, days 1-7) and prednisone (40 mg m-2, days 1-7). Courses were repeated every 4-6 weeks for a total of 12 courses. After the completion of 12 courses, responding patients received continuous treatment with chlorambucil (3 mg m-2 d-1) and prednisone (6 mg m-2 d-1) until relapse. Following the induction, 23 of 31 evaluated patients (74%) have responded to induction therapy of whom eight (26% of the 31 evaluated patients) achieved complete remission defined as disappearance of all clinical and laboratory features characteristic of WM. The overall median response duration, as of December 1988, has not yet been reached, while the overall median event-free survival duration for the entire population and for responding patients is 66 months in both groups. However, in responding patients the event-free survival duration after 66 months reaches a plateau. Toxicity was limited to transient nausea and vomiting (grade 2 according to WHO). In conclusion, this study demonstrates the efficacy and safety of an oral polychemotherapeutic treatment in the management of Waldenström's disease.

Blast crisis supervening on chronic lymphocytic leukaemia. A monoclonal progression of the disease as defined by cell surface markers

Acute leukaemia is a rare event during the course of chronic lymphocytic leukaemia (CLL), and only a small fraction of such cases have been shown to be true acute lymphoblastic crises. 1 case is described where both small lymphocytes and proliferating lymphoblasts have the same monoclonal pattern as defined by direct immunofluorescence of membrane-bound immunoglobulins. Previous cases are reviewed and do not appear to be mere coincidence: acute blast crisis may represent a part of the natural history of CLL.

Mast cell leukaemia: evidence for bone marrow origin of the pathological clone

A 57-year-old female patient, admitted for an acute abdominal syndrome, was found to have an extensive proliferation of mast cells both in the peripheral blood and the bone marrow. Cytochemical studies confirmed the mast cell characteristics of the pathological cell population, while the immunophenotype strongly suggested a bone marrow origin of this malignancy. The course of the disease was not affected by antiproliferative treatment and the patient, after progressive general deterioration, died of intractable haemorrhage. On both clinical and haematological criteria it seems possible to distinguish this rare case of primary mast leukaemia from the more common form of tissue mastocytosis with secondary leukaemia.

Cytofluorometric detection of chronic myelocytic leukemia supervening in a patient with chronic lymphocytic leukemia

An 82-year-old woman with stage I chronic lymphocytic leukemia presented with systemic symptoms, minimal adenopathy, hepatosplenomegaly, and anemia five years after the initial diagnosis was made and while receiving no therapy. Her white blood cell count was 231,000/mm3 with an absolute neutrophil count of 164,360/mm3 and lymphocyte count of 43,890/mm3. Peripheral blood smear inspection revealed both increased mature lymphocytes and myeloid cells at all stages of maturation. Flow cytometric analysis of forward- and right-angle light scatters demonstrated the presence of two populations of cells, one lymphoid, bearing predominantly lambda light chain surface immunoglobulin and showing phenotypic characteristics of B cell chronic lymphocytic leukemia (HLA-DR-positive, BL-1-positive, BL-2-positive, BL-7-positive, Leu-1-positive, Leu-10-positive, BL-5-negative, BL-6-negative, and OKM1-negative), and another granulocytic population expressing phenotypic features compatible with myeloid lineage (HLA-DR-negative, Leu-1-negative, BL-1-negative, BL-2-negative, BL-7-negative, Leu-10-negative, BL-5-positive, BL-6-negative, OKM1-positive, and surface immunoglobulin-negative). All of the peripheral blood cell metaphases were Philadelphia chromosome-positive after 24 hours of culture, confirming the diagnosis of chronic myelocytic leukemia, whereas all of the Epstein-Barr virus-treated B lymphocyte metaphases showed a normal karyotype after two weeks of culture. In this patient, analysis of surface antigens and immunoglobulin fractions by flow cytometry proved to be useful in recognizing concomitantly expressed leukemic lineages. This approach allows the increasing recognition of the heterogeneity of leukemic populations.

Chronic myelocytic leukemia as a second neoplasia in the course of chronic lymphocytic leukemia. Case report and review of the literature

A patient with chronic lymphocytic leukemia developed Ph1-positive chronic myelocytic leukemia after a 6-yr course of CLL. Chemotherapy for CLL consisted of chlorambucil and steroids, later vincristine and bleomycin; after resistance to these agents, cyclophosphamide, vincristine and prednisolone were applied. When CML was diagnosed, we found two morphologically distinct populations of malignant cells in the bone marrow; the Ph1-chromosome was identified, and immunological surface marker studies also demonstrated two distinct malignant cell populations. Up to now, only five cases of CML have been reported following CLL and one case accompanying it. Three patients were treated with cytostatic drugs, one patient by total body irradiation and two patients received no therapy. At present, it is not clear whether the development of CML during CLL represents a therapy-induced complication or an increased susceptibility to second malignancies due to the leukemic process itself or possibly to immunological deficiencies in CLL. Since two patients received no treatment for CLL, previous therapy does not seem to be a prerequisite for the development of CML.

Acute biphenotypic leukaemia (myeloid and null-ALL type) supervening in a myelodysplastic syndrome

An acute leukaemia was seen in a 72-year-old patient with a myelodysplastic syndrome (MDS) of 14 months duration, who had been treated only with steroids. The morphological appearance of the blast cells suggested a poorly differentiated cell type. Surface marker analysis, including double staining studies, showed the coexistence of a population of null acute lymphoblastic leukaemia (ALL) blast cells together with acute myeloid leukaemia type cells. No chromosomal alterations were detected. The change from a chronic MDS to an acute leukaemia of mixed (myeloid and null ALL) type suggests either transformation of a pre-existing abnormal clone or de novo appearance of two separate leukaemic clones.