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Alexander C. A History and Current Understanding of Acute Erythroid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:583-588. [PMID: 37246017 DOI: 10.1016/j.clml.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
Acute erythroid leukemia (AEL) is a highly aggressive subtype of acute myeloid leukemia. Since the first recognition of an erythroid-predominant hematologic malignancy in the early 20th century, AEL has gone through a turnstile of changing definitions and nomenclature, including eritoleucemia, erythremic myelosis, AML-M6 and pure erythroid leukemia. Ever-changing diagnostic criteria and under recognition have stifled our understanding of, and therapeutic options for, this rare erythroid-predominant myeloid neoplasm. It is now well-documented that true AEL, which is characterized primarily by immature erythroid proliferation, often harbors highly complex cytogenetic changes and multiple, deleterious TP53 mutations. These cytogenetic and molecular characteristics render current treatment approaches largely ineffective, and signal an urgent need for novel therapeutic modalities. Due to its rarity and aggressive nature, concerted collaborative efforts must be undertaken in order to improve the outcomes and treatment options for patients with AEL.
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Affiliation(s)
- Coltoff Alexander
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC.
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Takeda J, Yoshida K, Nakagawa MM, Nannya Y, Yoda A, Saiki R, Ochi Y, Zhao L, Okuda R, Qi X, Mori T, Kon A, Chiba K, Tanaka H, Shiraishi Y, Kuo MC, Kerr CM, Nagata Y, Morishita D, Hiramoto N, Hangaishi A, Nakazawa H, Ishiyama K, Miyano S, Chiba S, Miyazaki Y, Kitano T, Usuki K, Sezaki N, Tsurumi H, Miyawaki S, Maciejewski JP, Ishikawa T, Ohyashiki K, Ganser A, Heuser M, Thol F, Shih LY, Takaori-Kondo A, Makishima H, Ogawa S. Amplified EPOR/JAK2 Genes Define a Unique Subtype of Acute Erythroid Leukemia. Blood Cancer Discov 2022; 3:410-427. [PMID: 35839275 PMCID: PMC9894574 DOI: 10.1158/2643-3230.bcd-21-0192] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 05/05/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Acute erythroid leukemia (AEL) is a unique subtype of acute myeloid leukemia characterized by prominent erythroid proliferation whose molecular basis is poorly understood. To elucidate the underlying mechanism of erythroid proliferation, we analyzed 121 AEL using whole-genome, whole-exome, and/or targeted-capture sequencing, together with transcriptome analysis of 21 AEL samples. Combining publicly available sequencing data, we found a high frequency of gains and amplifications involving EPOR/JAK2 in TP53-mutated cases, particularly those having >80% erythroblasts designated as pure erythroid leukemia (10/13). These cases were frequently accompanied by gains and amplifications of ERG/ETS2 and associated with a very poor prognosis, even compared with other TP53-mutated AEL. In addition to activation of the STAT5 pathway, a common feature across all AEL cases, these AEL cases exhibited enhanced cell proliferation and heme metabolism and often showed high sensitivity to ruxolitinib in vitro and in xenograft models, highlighting a potential role of JAK2 inhibition in therapeutics of AEL. SIGNIFICANCE This study reveals the major role of gains, amplifications, and mutations of EPOR and JAK2 in the pathogenesis of pure erythroleukemia. Their frequent response to ruxolitinib in patient-derived xenograft and cell culture models highlights a possible therapeutic role of JAK2 inhibition for erythroleukemia with EPOR/JAK2-involving lesions. This article is highlighted in the In This Issue feature, p. 369.
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Affiliation(s)
- June Takeda
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichi Yoshida
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro M. Nakagawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Division of Hematopoietic Disease Control, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Akinori Yoda
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryunosuke Saiki
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yotaro Ochi
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Lanying Zhao
- Institute for the Advanced Study of Human Biology (WPI ASHBi), Kyoto University, Kyoto, Japan
| | - Rurika Okuda
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Xingxing Qi
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuto Mori
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ayana Kon
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichi Chiba
- Division of Genome Analysis Platform Development, National Cancer Center Research Institute, Tokyo, Japan
| | - Hiroko Tanaka
- M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Shiraishi
- Division of Genome Analysis Platform Development, National Cancer Center Research Institute, Tokyo, Japan
| | - Ming-Chung Kuo
- Division of Hematology−Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Cassandra M. Kerr
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Yasunobu Nagata
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Nobuhiro Hiramoto
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Akira Hangaishi
- Department of Hematology, NTT Medical Centre Tokyo, Tokyo, Japan
| | - Hideyuki Nakazawa
- Department of Hematology, Shinshu University Hospital, Matsumoto, Japan
| | - Ken Ishiyama
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Satoru Miyano
- M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeru Chiba
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan.,Japan Adult Leukemia Study Group, Japan
| | - Toshiyuki Kitano
- Department of Hematology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Centre Tokyo, Tokyo, Japan
| | - Nobuo Sezaki
- Department of Hematology, Chugoku Central Hospital, Hiroshima, Japan
| | | | - Shuichi Miyawaki
- Division of Hematology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Jaroslaw P. Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Lee-Yung Shih
- Division of Hematology−Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Akifumi Takaori-Kondo
- Department of Hematology/Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideki Makishima
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (WPI ASHBi), Kyoto University, Kyoto, Japan.,Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden.,Corresponding Author: Seishi Ogawa, Pathology and Tumor Biology, University of Kyoto, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606−8501, Japan. Phone: 81-75-753-9284; E-mail:
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Abstract
Malignancies of the erythroid lineage are rare but aggressive diseases. Notably, the first insights into their biology emerged over half a century ago from avian and murine tumor viruses-induced erythroleukemia models providing the rationale for several transgenic mouse models that unraveled the transforming potential of signaling effectors and transcription factors in the erythroid lineage. More recently, genetic roadmaps have fueled efforts to establish models that are based on the epigenomic lesions observed in patients with erythroid malignancies. These models, together with often unexpected erythroid phenotypes in genetically modified mice, provided further insights into the molecular mechanisms of disease initiation and maintenance. Here, we review how the increasing knowledge of human erythroleukemia genetics combined with those from various mouse models indicate that the pathogenesis of the disease is based on the interplay between signaling mutations, impaired TP53 function, and altered chromatin organization. These alterations lead to aberrant activity of erythroid transcriptional master regulators like GATA1, indicating that erythroleukemia will most likely require combinatorial targeting for efficient therapeutic interventions.
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Abstract
PURPOSE OF THE REVIEW Acute erythroleukemia (AEL) is a rare form of acute myeloid leukemia recognized by erythroblastic proliferation. Many controversies remain around diagnosis influencing prognostic and therapeutic implications relating to this unique leukemia subset. RECENT FINDINGS The 2016 WHO classification includes more clear and restrictive diagnostic criteria for AEL. Primary acute erythroid leukemia is associated with complex and high-risk karyotypes including chromosomes 5q and 7q abnormalities. Mutational data shows that AEL is characterized by far lower NPM1 and FLT3-ITD mutation rates and higher mutational rates in TP53 compared with other AML subtypes. Hypomethylating agents have shown therapeutic value in AEL. In this article, we discuss the evolving diagnostic concepts of erythroleukemia, genomics, clinical outcome, and promising therapeutic targets through an appraisal of the current literature.
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George TI, Bajel A. Diagnosis of rare subtypes of acute myeloid leukaemia and related neoplasms. Pathology 2021; 53:312-327. [PMID: 33676766 DOI: 10.1016/j.pathol.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
The diagnosis of acute myeloid leukaemia and related neoplasms in adults is challenging as this requires the integration of clinical findings, morphology, immunophenotype, cytogenetics, and molecular genetic findings. Lack of familiarity with rare subtypes of acute leukaemia hinders the diagnosis. In this review, we will describe diagnostic findings of several rare acute myeloid leukaemias and related neoplasms that primarily occur in adults including information on presentation, morphology, immunophenotype, genetics, differential diagnosis, and prognosis. Leukaemias discussed include blastic plasmacytoid dendritic cell neoplasm, acute myeloid leukaemia with t(6;9) (p23;q34.1); DEK-NUP214, acute myeloid leukaemia with inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2, MECOM, acute myeloid leukaemia with BCR-ABL1, acute leukaemias of ambiguous lineage, acute myeloid leukaemia with mutated RUNX1, pure erythroid leukaemia, acute panmyelosis with myelofibrosis, and acute basophilic leukaemia. Case studies with morphological features of the nine subtypes of acute myeloid leukaemia and related neoplasms have been included, and additional evidence available since publication of the 2016 World Health Organization Classification has been added to each subtype.
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Affiliation(s)
- Tracy I George
- University of Utah School of Medicine, Department of Pathology, Salt Lake City, UT, USA.
| | - Ashish Bajel
- Clinical Haematology, Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Melbourne, Vic, Australia
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Yadav DK, Paul T, Alhamar M, Inamdar K, Guo Y. Pure Erythroid Leukemia in a Sickle Cell Patient Treated with Hydroxyurea. Case Rep Oncol 2020; 13:857-862. [PMID: 32884531 PMCID: PMC7443646 DOI: 10.1159/000508361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/19/2022] Open
Abstract
We present a very rare case of pure erythroid leukemia arising in a young patient with sickle cell disease being treated with hydroxyurea for almost 5 years. Diagnosing and managing this rare condition has been a challenge and the majority of patients with pure erythroid leukemia have a very poor prognosis with survival in months despite treatment. This form of leukemia could be therapy related and in our case, hydroxyurea may have been responsible for the development of this aggressive condition.
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Affiliation(s)
- Dhiraj Kumar Yadav
- Department of Hematology and Oncology, Henry Ford Health System, Detroit, Michigan, USA
| | - Thushara Paul
- Department of Hematology and Oncology, Henry Ford Health System, Detroit, Michigan, USA
| | - Mohamed Alhamar
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Kedar Inamdar
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Yue Guo
- Department of Hematology and Oncology, Henry Ford Health System, Detroit, Michigan, USA
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7
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Kjeldsen E. A Novel Acquired t(2;4)(q36.1;q24) with a Concurrent Submicroscopic del(4)(q23q24) in An Adult with Polycythemia Vera. Cancers (Basel) 2018; 10:cancers10070214. [PMID: 29941837 PMCID: PMC6071118 DOI: 10.3390/cancers10070214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 12/27/2022] Open
Abstract
Background: Polycythemia vera (PV) is a clonal myeloid stem cell disease characterized by a growth-factor independent erythroid proliferation with an inherent tendency to transform into overt acute myeloid malignancy. Approximately 95% of the PV patients harbor the JAK2V617F mutation while less than 35% of the patients harbor cytogenetic abnormalities at the time of diagnosis. Methods and Results: Here we present a JAK2V617F positive PV patient where G-banding revealed an apparently balanced t(2;4)(q35;q21), which was confirmed by 24-color karyotyping. Oligonucleotide array-based Comparative Genomic Hybridization (aCGH) analysis revealed an interstitial 5.4 Mb large deletion at 4q23q24. Locus-specific fluorescent in situ hybridization (FISH) analyses confirmed the mono-allelic 4q deletion and that it was located on der(4)t(2;4). Additional locus-specific bacterial artificial chromosome (BAC) probes and mBanding refined the breakpoint on chromosome 2. With these methods the karyotype was revised to 46,XX,t(2;4)(q36.1;q24)[18]/46,XX[7]. Conclusions: This is the first report on a PV patient associated with an acquired novel t(2;4)(q36.1;q24) and a concurrent submicroscopic deletion del(4)(q23q24). The study also underscores the benefit of combined usage of FISH and oligo-based aCGH analysis in characterizing chromosomal abnormalities. The present findings provide additional clues to unravel important molecular pathways in PV to obtain the full spectrum of acquired chromosomal and genomic aberrations, which eventually may improve treatment options.
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Affiliation(s)
- Eigil Kjeldsen
- Cancer Cytogenetic Section, HemoDiagnostic Laboratory, Department of Hematology, Aarhus University Hospital, Tage-Hansens Gade 2, DK-8000 Aarhus C, Denmark.
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Imataki O, Takeuchi A, Uchida S, Yokokura S, Uemura M, Kadowaki N. Pure erythroid leukemia in a polymyositis patient treated with azathioprine. Rare Tumors 2018; 10:2036361318773847. [PMID: 29785257 PMCID: PMC5954579 DOI: 10.1177/2036361318773847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 03/21/2018] [Indexed: 11/16/2022] Open
Abstract
Acute erythroid leukemia, also known as acute myeloid leukemia-M6, may be associated with previous chemotherapy or immunosuppressive therapy. For 10 years, a 69-year-old Japanese female patient with pure erythroid leukemia (or acute myeloid leukemia-M6b) was treated for polymyositis with 50-100 mg/day azathioprine. She complained of dyspnea with low-grade fever and was diagnosed as having pure erythroid leukemia. Chromosomal analysis revealed a complex karyotype abnormality, with the deletion of 5q, -6, -7 and addition of 11q13. No morphological myelodysplastic changes were observed in her bone marrow cells. In this study, azathioprine accumulation was considered to be associated with the patient's leukemogenesis.
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Affiliation(s)
- Osamu Imataki
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Akihiro Takeuchi
- Department of Laboratory Medicine, Kagawa University Hospital, Miki, Japan
| | - Shumpei Uchida
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Shigeyuki Yokokura
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Makiko Uemura
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Norimitsu Kadowaki
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
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De novo pure erythroid leukemia: refining the clinicopathologic and cytogenetic characteristics of a rare entity. Mod Pathol 2018; 31:705-717. [PMID: 29327715 DOI: 10.1038/modpathol.2017.175] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 11/08/2022]
Abstract
Per the revised fourth edition World Health Organization classification of acute myeloid leukemia, pure erythroid leukemia is now the sole type of acute erythroid leukemia. The diagnosis of this rare entity is often challenging and the cytologic overlap with non-neoplastic (eg, megaloblastic anemia) and neoplastic entities (eg, other types of acute leukemia and non-hematopoietic malignancies) warrants a significant degree of clinical, laboratory, immunophenotypic, and genetic investigation. Given the limited number of reports of this rare and diagnostically challenging entity, we report detailed clinicopathologic characteristics from 15 patients, the largest series thus far, of primary de novo pure erythroid leukemia to provide further diagnostic insights into this entity and reveal strategies for making the diagnosis. We found that de novo pure erythroid leukemia is a disease of adults (median age 68 years), exhibits a striking male predominance, is universally associated with an abnormal karyotype and has an exceedingly poor overall median survival of 1.4 months. Given the general inability of immunophenotypic markers to discriminate neoplastic from non-neoplastic erythroid proliferations, key features identified in this study to help establish the diagnosis of pure erythroid leukemia and exclude mimickers include circulating pronormoblasts, clear-cut dysplasia in erythroid, granulocytic, and/or megakaryocytic lineage, utilization of a broad immunophenotypic panel, TP53 immunohistochemical positivity, and identification of a complex, often highly complex, karyotype. Given the gravity of a diagnosis of de novo pure erythroid leukemia, it should be rendered with utmost confidence.
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Ryu S, Park HS, Kim SM, Im K, Kim JA, Hwang SM, Yoon SS, Lee DS. Shifting of erythroleukemia to myelodysplastic syndrome according to the revised WHO classification: Biologic and cytogenetic features of shifted erythroleukemia. Leuk Res 2018; 70:13-19. [PMID: 29729583 DOI: 10.1016/j.leukres.2018.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/19/2022]
Abstract
The 2016 revision of the World Health Organization (WHO) classification of tumours of haematopoietic and lymphoid tissues was published. According to 2016 WHO criteria, diagnostic criteria of acute erythroid leukemia was revised. We reassessed 34 de novo acute erythroid leukemia (AEL) diagnosed by 2008 WHO criteria, according to 2016 WHO criteria. A total of 623 patients (excluding M3) with acute myeloid leukemia including 34 patients with AEL were enrolled. Among 34 patients diagnosed with AEL, diagnosis was shifted to MDS-EB in 28 patients (28/34, 82.3%) and MDS-U in 2 patients (2/34, 5.9%), while remained as AEL in 4 patients (4/34, 11.8%) according to 2016 WHO criteria. Interphase FISH for cytogenetic changes of MDS (-5/del(5q), -7/del(7q), del(20q), +8) revealed cytogenetic aberrations in 50.0% (17/34) of AEL 2008 group. AEL 2008 group showed higher frequency of complex cytogenetic abnormalities and higher MDS related cytogenetic abnormalities than AML excluding AEL group. Transformation to another AML subtype was noted in 10% in AEL shifted to MDS. Majority (88.2%) of AEL by 2008 WHO criteria was reclassified to MDS by 2016 WHO criteria. Clinical characteristics of shifted AEL were similar to those of MDS rather than de novo AML.
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Affiliation(s)
- Sohee Ryu
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Sue Park
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyongok Im
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Ah Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung-Soo Yoon
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Hematology/Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Soon Lee
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Abstract
PURPOSE OF REVIEW The 2016 WHO classification of hematopoietic and lymphoid neoplasms alters the diagnostic criteria for erythroleukemia, including eliminating the erythroid/myeloid type of acute erythroleukemia, which was a prior subcategory of acute myeloid leukemia, not otherwise specified. Only pure erythroid leukemia remains in the WHO classification. This review will summarize the literature that contributed to that classification change as well as recent literature on the significance of the change. RECENT FINDINGS There is now a large body of literature on the negative prognostic impact of erythroid predominance, defined as 50% or more bone marrow erythroid cells, in myelodysplastic syndromes (MDSs). Recent studies have found similarities between erythroleukemia, especially the erythroid/myeloid type, and the erythroid-rich MDS cases. On the basis of these data, the WHO now reclassifies cases of the prior erythroid/myeloid acute erythroleukemia group based on the total blast cell count. This change moves such cases into an MDS category, usually MDS with excess blasts. This approach, however, may cloud the significance of erythroid predominance in this group of patients. SUMMARY The report clarifies the current criteria for a diagnosis of erythroleukemia as well as the ongoing challenges in classifying this group of erythroid rich bone marrow disorders.
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Re-evaluation of acute erythroid leukemia according to the 2016 WHO classification. Leuk Res 2017; 61:39-43. [PMID: 28886412 DOI: 10.1016/j.leukres.2017.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 11/21/2022]
Abstract
In the recent update of WHO classification, the definition of myeloid neoplasms with erythroid predominance has been modified shifting the main criteria for calculating blast percentage from non-erythroid cells (NEC) to all nucleated marrow cells (ANC). Thus, the cases previously classified as erythroid/myeloid subtype of acute erythroid leukemia (AEL) based on the 2008 WHO will now be categorized either as myelodysplastic syndrome with excess blasts (MDS-EB) or acute myeloid leukemia, not otherwise specified (AML-NOS). However, the clinical significance of this new classification has not been demonstrated. Thus, we reviewed a leukemia database and reclassified 38 cases previously diagnosed as AEL, erythroid/myeloid subtype, with the consideration of 2016 revision criteria. Twenty seven (71%) of them had >20% blasts in NEC but less than 20% blasts in ANC, and 11 (29%) had >20% in both NEC and ANC. There was no significant difference in overall survivals (OS) among AEL, MDS-EB, and AML-NOS (non-erythroid predominance, NEP). However, AML with myelodysplasia-related changes showed significant shorter OS than AEL, MDS-EB and AML-NOS (NEP). Our results indicate that in myeloid neoplasm with erythroid predominance, patients with >20% blasts, of either NEC or ANC, share similar clinical laboratory features and survival outcomes with AML-NOS.
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13
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Qiu S, Jiang E, Wei H, Lin D, Zhang G, Wei S, Zhou C, Liu K, Wang Y, Liu B, Liu Y, Gong B, Gong X, Feng S, Mi Y, Han M, Wang J. An analysis of 97 previously diagnosed de novo adult acute erythroid leukemia patients following the 2016 revision to World Health Organization classification. BMC Cancer 2017; 17:534. [PMID: 28793875 PMCID: PMC5550989 DOI: 10.1186/s12885-017-3528-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022] Open
Abstract
Background The incidence of acute erythroid leukemia subtype (AEL) is rare, accounting for 5% of cases of acute myeloid leukemia (AML), and the outcome is dismal. However, in 2016 revision to the WHO classification, the subcategory of AEL has been removed. Myeloblasts are redefined as the percentage of total marrow cells, not non-erythroid cells. Therefore, the previously diagnosed AEL cases are currently diagnosed as AML or myelodyspalstic syndrome (MDS) according to new criteria. Methods We respectively reviewed cases of 97 de novo previously diagnosed AEL and all the patients were diagnosed as AML or MDS according to the new classification scheme, and then the clinical characteristics of these two subtypes were compared. Statistical analyses were performed by SPSS software version 18.0. Results The median age was 37 years-old, the two-thirds of previous AEL cases were diagnosed as MDS, and there was no obvious difference between two subtypes except for male/female ratio and age. Cytogenetic, rather than MDS/AML subtypes, can better represent the prognostic factor of previously diagnosed AEL patients. When the cytogenetic risk of patients belonged to MRC intermediate category and age were below 40 years-old in previous AEL cases, the patients who received induction chemotherapy without transplantation had a similar survival compared with the patients who underwent transplantation (3-year OS: 67.2% vs 68.5%). Conclusions Cytogenetic, rather than MDS/AML subtypes, can better represent the prognostic factor of previously diagnosed AEL patients. Transplantation was a better choice for those whose cytogenetic category was unfavorable. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3528-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shaowei Qiu
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Erlie Jiang
- Department of Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Hui Wei
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Dong Lin
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Guangji Zhang
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Shuning Wei
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Chunlin Zhou
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Kaiqi Liu
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Ying Wang
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Bingcheng Liu
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Yuntao Liu
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Benfa Gong
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Xiaoyuan Gong
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Sizhou Feng
- Department of Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Yingchang Mi
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China
| | - Mingzhe Han
- Department of Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Jianxiang Wang
- Department of Leukemia Therapy, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), 288 Nanjing Road, Tianjin, 300020, People's Republic of China.
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Almeida AM, Prebet T, Itzykson R, Ramos F, Al-Ali H, Shammo J, Pinto R, Maurillo L, Wetzel J, Musto P, Van De Loosdrecht AA, Costa MJ, Esteves S, Burgstaller S, Stauder R, Autzinger EM, Lang A, Krippl P, Geissler D, Falantes JF, Pedro C, Bargay J, Deben G, Garrido A, Bonanad S, Diez-Campelo M, Thepot S, Ades L, Sperr WR, Valent P, Fenaux P, Sekeres MA, Greil R, Pleyer L. Clinical Outcomes of 217 Patients with Acute Erythroleukemia According to Treatment Type and Line: A Retrospective Multinational Study. Int J Mol Sci 2017; 18:E837. [PMID: 28420120 PMCID: PMC5412421 DOI: 10.3390/ijms18040837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 04/06/2017] [Indexed: 01/01/2023] Open
Abstract
Acute erythroleukemia (AEL) is a rare disease typically associated with a poor prognosis. The median survival ranges between 3-9 months from initial diagnosis. Hypomethylating agents (HMAs) have been shown to prolong survival in patients with myelodysplastic syndromes (MDS) and AML, but there is limited data of their efficacy in AEL. We collected data from 210 AEL patients treated at 28 international sites. Overall survival (OS) and PFS were estimated using the Kaplan-Meier method and the log-rank test was used for subgroup comparisons. Survival between treatment groups was compared using the Cox proportional hazards regression model. Eighty-eight patients were treated with HMAs, 44 front line, and 122 with intensive chemotherapy (ICT). ICT led to a higher overall response rate (complete or partial) compared to first-line HMA (72% vs. 46.2%, respectively; p ≤ 0.001), but similar progression-free survival (8.0 vs. 9.4 months; p = 0.342). Overall survival was similar for ICT vs. HMAs (10.5 vs. 13.7 months; p = 0.564), but patients with high-risk cytogenetics treated with HMA first-line lived longer (7.5 for ICT vs. 13.3 months; p = 0.039). Our results support the therapeutic value of HMA in AEL.
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Affiliation(s)
- Antonio M Almeida
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Thomas Prebet
- Institut Paoli Calmettes, Marseille, France and Yale New Haven Hospital, New Haven, CT 06512, USA.
| | - Raphael Itzykson
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | | | - Haifa Al-Ali
- University Hospital of Halle, 06120 Halle, Germany.
| | - Jamile Shammo
- Rush University Medical Center, Chicago, IN 60612, USA.
| | | | | | - Jaime Wetzel
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Pellegrino Musto
- RCCS-CROB, Referral Cancer Center of Basilicata, 85028 Rionero in Vulture (Pz), Italy.
| | | | - Maria Joao Costa
- Centro Hospitalar Lisboa Norte Hospital Santa Maria, 1649-035 Lisbon, Portugal.
| | - Susana Esteves
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Sonja Burgstaller
- Department of Internal Medicine IV, Hospital Wels-Grieskirchen, 4600 Wels, Austria.
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, 6020 Innsbruck, Austria.
| | - Eva M Autzinger
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Wilhelminenspital, 1160 Vienna, Austria.
| | - Alois Lang
- Internal Medicine, Hospital Feldkirch,6800 Feldkirch, Austria.
| | - Peter Krippl
- Department of Internal Medicine, Hospital Fürstenfeld, 8280 Fürstenfeld, Austria.
| | - Dietmar Geissler
- Department for Internal Medicine, Klinikum Klagenfurt am Wörthersee, 9020 Pörtschach am Wörthersee, Austria.
| | | | | | - Joan Bargay
- Hospital Son Llatzer, 07198 Palma de Mallorca, Spain.
| | | | - Ana Garrido
- Hospital de la Santa Creu i Sant Pau, 08026 Barcelona, Spain.
| | | | | | | | - Lionel Ades
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Pierre Fenaux
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Mikkael A Sekeres
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Richard Greil
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
| | - Lisa Pleyer
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
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15
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Ko PS, Liu YC, Yeh CM, Gau JP, Yu YB, Hsiao LT, Tzeng CH, Chen PM, Chiou TJ, Liu CJ, Liu JH. The uniqueness of morphological features of pure erythroid leukemia in myeloid neoplasm with erythroid predominance: A reassessment using criteria revised in the 2016 World Health Organization classification. PLoS One 2017; 12:e0172029. [PMID: 28196090 PMCID: PMC5308818 DOI: 10.1371/journal.pone.0172029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/30/2017] [Indexed: 11/19/2022] Open
Abstract
We reviewed 97 consecutive cases of myeloid neoplasm with erythroid predominance (MN-EP) between 2000 and 2015. Following 2016 WHO classification, MN-EP patients were classified into four groups. Eight pure erythroid leukemia (PEL) (including t-MN and AML-MRC morphologically fulfilled criteria for PEL) patients had dismal outcomes (median OS: 1 month) and showed more bone marrow fibrosis, worse performance status (PS) and higher serum lactate dehydrogenase (LDH) at diagnosis than the other groups. In the univariate analysis, risks of death in MN-EP patients included the morphologic features of PEL, very poor cytogenetic risk by IPSS-R, bone marrow fibrosis, leukocytosis, anemia, hypoalbuminemia, high LDH, and poor PS. In the multivariate analysis, independent predictors of death were morphologic features of PEL (adjusted hazards ratio [HR] 3.48, 95% confidence interval [CI] 1.24–9.74, p = 0.018), very poor cytogenetic risk by IPSS-R (adjusted HR 2.73, 95% CI 1.22–6.10, p = 0.015), hypoalbuminemia (< 3.7 g/dl) (adjusted HR 2.33, 95% CI 1.10–4.91, p = 0.026) and high serum LDH (≥ 250 U/L) (adjusted HR 2.36, 95% CI 1.28–4.36, p = 0.006). Poor or unfavorable risk in different cytogenetic risk systems independently predicted death and UKMRC-R was the best model.
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Affiliation(s)
- Po-Shen Ko
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chiu-Mei Yeh
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Hwai Tzeng
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Min Chen
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (C-JL); (J-HL)
| | - Jin-Hwang Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Biopharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan
- Chong Hin Loon Memorial Cancer and Biotherapy Research Center, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (C-JL); (J-HL)
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Erythroleukemia shares biological features and outcome with myelodysplastic syndromes with excess blasts: a rationale for its inclusion into future classifications of myelodysplastic syndromes. Mod Pathol 2016; 29:1541-1551. [PMID: 27562492 DOI: 10.1038/modpathol.2016.146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/27/2016] [Accepted: 07/04/2016] [Indexed: 11/08/2022]
Abstract
Erythroleukemia was considered an acute myeloid leukemia in the 2008 World Health Organization (WHO) classification and is defined by the presence of ≥50% bone marrow erythroblasts, having <20% bone marrow blasts from total nucleated cells but ≥20% bone marrow myeloblasts from nonerythroid cells. Erythroleukemia shares clinicopathologic features with myelodysplastic syndromes, especially with erythroid-predominant myelodysplastic syndromes (≥50% bone marrow erythroblasts). The upcoming WHO revision proposes to eliminate the nonerythroid blast cell count rule and to move erythroleukemia patients into the appropriate myelodysplastic syndrome category on the basis of the absolute blast cell count. We conducted a retrospective study of patients with de novo erythroleukemia and compared their clinico-biological features and outcome with those of de novo myelodysplastic syndromes, focusing on erythroid-predominant myelodysplastic syndromes. Median overall survival of 405 erythroid-predominant myelodysplastic syndromes without excess blasts was significantly longer than that observed in 57 erythroid-predominant refractory anemias with excess blasts-1 and in 59 erythroleukemias, but no significant difference was observed between erythroid-predominant refractory anemias with excess blasts-1 and erythroleukemias. In this subset of patients with ≥50% bone marrow erythroblasts and excess blasts, the presence of a high-risk karyotype defined by the International Prognostic Scoring System or by the Revised International Prognostic Scoring System was the main prognostic factor. In the same way, the survival of 459 refractory anemias with excess blasts-2, independently of having ≥20% bone marrow blasts from nonerythroid cells or not, was almost identical to the observed in 59 erythroleukemias. Interestingly, 11 low-blast count erythroleukemias with 5 to <10% bone marrow blasts from total nucleated cells showed similar survival than the rest of erythroleukemias. Our data suggest that de novo erythroleukemia is in the spectrum of myelodysplastic syndromes with excess blasts and support its inclusion into future classifications of myelodysplastic syndromes.
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17
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Acute myeloid leukaemia and myelodysplastic syndromes with 50% or greater erythroblasts: a diagnostic conundrum. Pathology 2015; 47:289-93. [DOI: 10.1097/pat.0000000000000244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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18
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Wong E, Ling V, Westerman D, Morgan S, Juneja S. How unique is pure erythroid leukaemia? A retrospective analysis of seven cases and review of the literature. J Clin Pathol 2015; 68:301-5. [PMID: 25609576 DOI: 10.1136/jclinpath-2014-202740] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Pure erythroid leukaemia (PEL) is a rare subtype of acute myeloid leukaemia (AML) and its clinicopathological features are not well-defined. The aim of this study was to describe the immunophenotypic, cytogenetic and clinical features of PEL and to compare these with cases of AML with ≥ 50% erythroblasts. METHODS Cases of PEL according to WHO morphological criteria diagnosed at three institutions from 1997 to 2013 were included. A comparison cohort comprised of AML with ≥ 50% erythroblasts. The clinical, histopathology, immunophenotypic and cytogenetic features of cases were analysed. We also reviewed the existing literature on PEL, and combined our cohort with previously reported cases of PEL in a pooled analysis. RESULTS There were seven cases of PEL diagnosed at our institutions. There was a high incidence of either prior chemoradiotherapy exposure or evolution from pre-existing myelodysplastic syndrome (MDS) (71%). The leukaemic blasts frequently expressed glycophorin C (100%), CD117 (83%) and were myeloperoxidase negative (83%). Complex karyotypes were present in 83% of cases. Median overall survival was 2.9 months. Compared with AML with ≥ 50% erythroblasts, cases of PEL demonstrated a higher incidence of adverse-risk cytogenetics (p=0.01) and prior exposure to chemoradiotherapy (p=0.01). CONCLUSIONS PEL appears to be a unique entity that is often secondary or therapy related, commonly features a complex karyotype and has a poor prognosis. It is morphologically and immunophenotypically distinct from other cases of AML with erythroid hyperplasia.
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Affiliation(s)
- Eric Wong
- Department of Diagnostic Haematology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Victoria Ling
- Department of Diagnostic Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - David Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Morgan
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Surender Juneja
- Department of Diagnostic Haematology, Royal Melbourne Hospital, Melbourne, Victoria, Australia University of Melbourne, Melbourne, Victoria, Australia
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19
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Oberley MJ, Yang DT. Pure Erythroid Leukemia Presenting in a HIV-Positive Patient. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:e35-8. [DOI: 10.1016/j.clml.2013.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/24/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022]
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20
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Abstract
Acute erythroid leukemias encompass 2 main subtypes: acute erythroleukemia (erythroid/myeloid subtype) and pure erythroid leukemia. This article reviews the main clinicopathologic features of the acute erythroid leukemias and the criteria used to diagnose them. In this article, the differential diagnosis between acute erythroid leukemias and their mimics is discussed and helpful morphologic clues and diagnostic tests that help arrive at the correct diagnosis are provided. The appropriate application of diagnostic criteria, including ancillary testing, such as immunophenotyping, cytogenetics, and molecular genetic testing, is essential to categorize bone marrow erythroid proliferations.
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Affiliation(s)
- Robert P Hasserjian
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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21
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Wang SA, Hasserjian RP. Erythroid proliferations in myeloid neoplasms. Hum Pathol 2012; 43:153-64. [PMID: 22154053 DOI: 10.1016/j.humpath.2011.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 08/10/2011] [Accepted: 08/12/2011] [Indexed: 02/03/2023]
Abstract
Prominent erythroid proliferations (in which erythroid elements comprise ≥50% of total bone marrow cells) can be seen in various hematopoietic stem cell neoplasms. The myeloproliferative neoplasm polycythemia vera exhibits effective, overexuberant erythropoiesis resulting in an increased red blood cell mass; in contrast, most other diseases characterized by erythroid predominance exhibit ineffective hemopoiesis. The latter include acute erythroid leukemia (erythroid-myeloid and pure erythroid leukemia subtypes) as well as some cases of myelodysplastic syndromes, acute myeloid leukemia with myelodysplasia-related changes, and therapy-related myeloid neoplasms. Some nonneoplastic reactive conditions may also manifest a striking bone marrow erythroid predominance. In this article, we review the literature relevant to this group of diseases for a better understanding of their clinicopathologic features and surrounding controversies. We also examine the position of neoplastic erythroid proliferations in the current 2008 World Health Organization Classification of Myeloid Neoplasms and provide recommendations as to how to approach the differential diagnosis of this group of diseases.
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Affiliation(s)
- Sa A Wang
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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22
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Xu M, Finn LS, Tsuchiya KD, Thomson B, Pollard J, Rutledge J. Pure erythroid leukemia following precursor B-cell lymphoblastic leukemia. Pediatr Dev Pathol 2012; 15:76-8. [PMID: 21877942 DOI: 10.2350/11-04-1029-cr.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Therapy-related acute myeloid leukemia is an unfortunate sequel to current multimodal intensive chemotherapy. The patient described was diagnosed with pure erythroleukemia, AML-M6b, during therapy for precursor B-cell acute lymphoblastic leukemia. To the best of our knowledge, this is the first report of this unusual association.
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Affiliation(s)
- Min Xu
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA.
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23
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Liu CJ, Hong YC, Yang CF, Liu SH, Gau JP, Liu JH, Hsiao LT, Liu CY, Yu YB, Tzeng CH. Clinicopathologic features and outcome of acute erythroid leukemia based on 2008 revised World Health Organization classification. Leuk Lymphoma 2011; 53:289-94. [PMID: 21780998 DOI: 10.3109/10428194.2011.607526] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report 67 patients with acute erythroid leukemia (erythroleukemia) based on the World Health Organization (WHO) 2008 classification. Reviewing the clinicopathologic features, cytogenetics and outcomes, the characteristics of erythroleukemia resembled myelodysplastic syndromes (MDS). Patients with poor performance status, advanced anemia and poor-risk cytogenetics had significantly inferior outcomes. The International Prognostic Scoring System (IPSS) for MDS is useful to differentiate the prognosis of erythroleukemia.
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Affiliation(s)
- Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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24
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Wang HY, Huang LJS, Liu Z, Garcia R, Li S, Galliani CA. Erythroblastic sarcoma presenting as bilateral ovarian masses in an infant with pure erythroid leukemia. Hum Pathol 2011; 42:749-58. [PMID: 21237494 DOI: 10.1016/j.humpath.2010.08.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Revised: 08/09/2010] [Accepted: 08/20/2010] [Indexed: 11/30/2022]
Abstract
Pure erythroid leukemia is a rare subtype of acute erythroid leukemia that is characterized by a predominant erythroid population, and erythroblastic sarcoma has not yet been described in the English literature. Here, we report a first case of erythroblastic sarcoma that presented as bilateral ovarian masses in a 3 ½-month-old infant girl with pure erythroid leukemia. Bone marrow aspirate and biopsy showed that the marrow was completely replaced by large-sized blasts consistent with erythroblasts. Immunophenotypically, both the tumor cells from the ovarian mass and bone marrow blasts were positive for CD117, glycophorin A, and hemoglobin A, demonstrating erythroid differentiation. Reverse transcriptase polymerase chain reaction showed that the tumor cells from ovarian mass expressed hemoglobin F and α1 spectrin, confirming their erythroid lineage. Conventional karyotype of the bone marrow aspirates revealed del(6)(q23q25) and trisomy 7 in all 21 cells examined. Fluorescence in situ hybridization of the ovarian mass demonstrated loss of c-myeloblastosis viral oncogene (C-MYB) at 6q23 locus in 41% of the cells, and deletion of chromosome 7 and 7q in 37% and 66% of cells, respectively. Taken together, we showed, for the first time, that pure erythroid leukemia presented as a myeloid sarcoma in the form of ovarian masses.
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Affiliation(s)
- Huan-You Wang
- Department of Pathology, University of California San Diego Health Sciences, La Jolla, CA 92037-0987, USA.
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25
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Santos FPS, Bueso-Ramos CE, Ravandi F. Acute erythroleukemia: diagnosis and management. Expert Rev Hematol 2010; 3:705-18. [PMID: 21091147 DOI: 10.1586/ehm.10.62] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Acute erythroleukemia is a rare subtype of acute myeloid leukemia that has undergone several changes in classification over the past 30 years. There are two subtypes of acute erythroleukemia: the more common erythroid/myeloid subtype, defined by the presence of increased erythroid cells and myeloid blasts; and the rarer, pure erythroid subtype, characterized by expansion of immature erythroid cells only. The erythroid/myeloid subtype of acute erythroleukemia is closely related to acute myeloid leukemia with myelodysplasia-related changes, and is frequently characterized by morphological dysplasia and complex karyotype. Pure erythroleukemia is a very uncommon subtype of leukemia associated with a very poor response and survival to current available therapeutic agents. Treatment results for this disease are suboptimal and new drugs are needed. This article summarizes current knowledge in the field of acute erythroleukemia.
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Affiliation(s)
- Fabio P S Santos
- Department of Leukemia, University of Texas: MD Anderson Cancer Center, Houston, TX, USA
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26
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Abstract
CONTEXT Acute erythroid leukemia (AEL) is an uncommon type of acute myeloid leukemia (AML), representing less than 5% of all cases. Acute erythroid leukemia is characterized by a predominant erythroid proliferation, and in the current World Health Organization (WHO) classification scheme there are 2 subtypes: erythroleukemia (erythroid/myeloid leukemia) and pure erythroid leukemia. Morphologic findings are most important for establishing the diagnosis. The erythroleukemia subtype, which is most common, is defined as the presence of 50% or more erythroid precursors and 20% or more blasts in the nonerythroid component. The pure erythroid leukemia subtype is composed of 80% or more immature erythroblasts. Although these morphologic criteria appear straightforward, AEL overlaps with other types of AML and myelodysplastic syndrome that are erythroid rich. OBJECTIVE To provide an update of AEL, including clinical presentation, morphologic features, immunophenotype, and cytogenetic and molecular data. As the erythroleukemia subtype is most common, the literature and this review are biased towards this subtype of AEL. DATA SOURCES Clinicopathologic, cytogenetic, and molecular information were extracted from our review of pertinent literature and a subset of AEL cases in the files of The University of Texas M. D. Anderson Cancer Center (Houston) and University of South Alabama (Mobile). CONCLUSIONS The current WHO criteria for establishing the diagnosis of AEL reduce the frequency of this entity, as cases once classified as the erythroleukemia subtype are now reclassified as other types of AML, particularly AML with myelodysplasia-related changes and therapy-related AML. This reclassification also may have prognostic significance for patients with the erythroleukemia subtype of AEL. In contrast, the current WHO criteria appear to have little impact on the frequency and poor prognosis of patients with the pure erythroid leukemia subtype of AEL. Molecular studies, preferably using high-throughput methods, are needed for a better understanding of the pathogenesis of AEL, and for developing diagnostic and prognostic markers.
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Affiliation(s)
- Zhuang Zuo
- Department of Hematopathology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Acute erythroid leukemia: a reassessment using criteria refined in the 2008 WHO classification. Blood 2009; 115:1985-92. [PMID: 20040759 DOI: 10.1182/blood-2009-09-243964] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Acute erythroid leukemia (AEL) is a rare type of acute myeloid leukemia (AML) for which diagnostic criteria have been refined in the 2008 World Health Organization (WHO) classification of AML. The relationship of AEL to myelodysplastic syndromes (MDSs) and to AML with myelodysplasia-related changes (AML-MRC) is not clearly defined. We conducted a retrospective, multi-institutional study of patients with AEL and compared them with patients with MDS or AML-MRC with erythroid hyperplasia (> or = 50% erythroid cells). Among a total of 124 patients with AEL, 32% had a history of MDS or chronic cytopenia, 32% had therapy-related disease, and 35% had de novo disease. Sixty-four percent of patients had unfavorable AML risk-group karyotypes. FLT3 and RAS mutations were infrequent, occurring in 6% and 2%, respectively. The median overall survival (OS) of all AEL patients was 8 months, comparable with that of patients with MDS or AML-MRC with erythroid hyperplasia. The OS was related to cytogenetic risk group, but not blast count or morphologic dysplasia. Our findings suggest that AEL is in the continuum of MDS and AML with erythroid hyperplasia, where karyotype rather than an arbitrary blast cutoff represents the most important prognostic factor.
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Santos FPS, Faderl S, Garcia-Manero G, Koller C, Beran M, O'Brien S, Pierce S, Freireich EJ, Huang X, Borthakur G, Bueso-Ramos C, de Lima M, Keating M, Cortes J, Kantarjian H, Ravandi F. Adult acute erythroleukemia: an analysis of 91 patients treated at a single institution. Leukemia 2009; 23:2275-80. [PMID: 19741728 DOI: 10.1038/leu.2009.181] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acute erythroleukemia (AML-M6) is an uncommon subtype of acute myeloid leukemia (AML); it is considered to have a poor prognosis. From 1 January 1980 to 21 May 2008, 91 patients with newly diagnosed AML-M6 were seen at the University of Texas-M.D. Anderson Cancer Center (UT-MDACC). Forty-five patients (50%) had a history of myelodysplatic syndrome (MDS), compared with 41% in our control group (patients with other AML subtypes) (P=0.08). Poor-risk cytogenetics were more common in patients with AML-M6 (61% versus 38%, P=0.001). Complete remission rates were 62% for patients with AML-M6, comparing with 58% for the control group (P=0.35). Median disease free survival (DFS) for patients with AML-M6 was 32 weeks, versus 49 weeks for the control group (P=0.05). Median overall survival (OS) of patients with AML-M6 was 36 weeks, compared with 43 weeks for the control group (P=0.60). On multivariate analysis for DFS and OS, AML-M6 was not an independent risk factor. AML-M6 is commonly associated with a previous diagnosis of MDS and poor-risk karyotype. The diagnosis of AML-M6 does not impart by itself a worse prognosis, and treatment decisions on this disease should be guided by well known AML prognostic factors.
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Affiliation(s)
- F P S Santos
- Department of Leukemia, University of Texas-M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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