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Zhang Y, Li K, Li X, Wang H, Li T, Long F. Concurrent Pleural and Pericardial Involvement in a Patient With De Novo Pure Erythroid Leukemia. Ann Lab Med 2024; 44:179-182. [PMID: 37840313 PMCID: PMC10628751 DOI: 10.3343/alm.2023.0252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/12/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Affiliation(s)
- Yun Zhang
- Department of Clinical Laboratory, The District People’s Hospital of Zhangqiu, Jinan, Shandong, China
| | - Kechao Li
- Department of Clinical Laboratory, The District People’s Hospital of Zhangqiu, Jinan, Shandong, China
| | - Xue Li
- Department of Health Ward, The District People’s Hospital of Zhangqiu, Jinan, Shandong, China
| | - Hui Wang
- Department of Laboratory Medicine, Hebei Yanda Ludaopei Hospital, Langfang, China
| | - Ting Li
- Department of Laboratory Medicine, Beijing Ludaopei Hospital, Beijing, China
| | - Fang Long
- Department of Clinical Laboratory, Sichuan Provincial Maternity and Child Health Care Hospital, The Affiliated Women’s and Children’s Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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2
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Zhang W, Dun J, Li H, Liu J, Chen H, Yu H, Xu J, Zhou F, Qiu Y, Hao J, Hu Q, Wu X. Analysis 33 patients of non-DS-AMKL with or without acquired trisomy 21 from multiple centers and compared to 118 AML patients. Hematology 2023; 28:2231731. [PMID: 37522469 DOI: 10.1080/16078454.2023.2231731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Acute megakaryoblastic leukemia (AMKL) without Down syndrome (non-DS-AMKL) usually a worse outcome than DS-AMKL. Acquired trisomy 21(+21) was one of the most common cytogenetic abnormalities in non-DS-AMKL. Knowledge of the difference in the clinical characteristics and prognosis between non-DS-AMKL with +21 and those without +21 is limited. OBJECTIVE Verify the clinical characteristics and prognosis of non-DS-AMKL with +21. METHOD We retrospectively analyzed 33 non-DS-AMKL pediatric patients and 118 other types of AML, along with their clinical manifestations, laboratory data, and treatment response. RESULTS Compared with AMKL without +21, AMKL with +21 has a lower platelet count (44.04 ± 5.01G/L) at onset (P > 0.05). Differences in remission rates between AMKL and other types of AML were not significant. Acquired trisomy 8 in AMKL was negatively correlated with the long-term OS rate (P < 0.05), while +21 may not be an impact factor. Compared with the other types of AML, AMKL has a younger onset age (P < 0.05), with a mean of 22.27 months. Anemia, hemorrhage, lymph node enlargement, lower white blood cell, and complex karyotype were more common in AMKL (P < 0.05). AMKL has a longer time interval between onset to diagnosis (53.61 ± 71.15 days) (P < 0.05), and patients with a diagnosis delay ≥3 months always presented as thrombocytopenia or pancytopenia initially. CONCLUSIONS Due to high heterogeneity, high misdiagnosis rate, and myelofibrosis, parts of AMKL may take a long time to be diagnosed, requiring repeated bone marrow punctures. Complex karyotype was common in AMKL. +21 may not be a promising indicator of a poor prognosis.
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Affiliation(s)
- Wenzhi Zhang
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jianxin Dun
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Hui Li
- Department of Hematology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jingzhen Liu
- Department of Pediatrics, The Central Hospital of Enshi Autonomous Prefecture, Enshi, People's Republic of China
| | - Hongbo Chen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jiawei Xu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yining Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jinjin Hao
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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3
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Wang Z, Guo J, Liu J. A Patient with Acute Erythroid Leukaemia with Granular Leukaemic Cells Mimicking Megakaryoblast. Indian J Hematol Blood Transfus 2023; 39:513-514. [PMID: 37304484 PMCID: PMC10247638 DOI: 10.1007/s12288-022-01616-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Zhaoliang Wang
- Department of Laboratory Medicine, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, People’s Republic of China
| | - Jiaquan Guo
- Department of Laboratory Medicine, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, People’s Republic of China
| | - Jinlin Liu
- Department of Clinical Laboratory, Health Science Center, South China Hospital, Shenzhen University, 1 Fuxin Road, 518116 Shenzhen, People’s Republic of China
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4
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Parkhi M, Mallik N, Lad D, Sachdeva MUS, Bal A, Malhotra P, Mitra S. Autopsy findings of acute erythroid leukemia. Autops Case Rep 2023; 13:e2023429. [PMID: 37287566 PMCID: PMC10243748 DOI: 10.4322/acr.2023.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/30/2023] [Indexed: 06/09/2023]
Abstract
Acute erythroid leukemia (AEL) is an exceedingly uncommon but distinct hematological malignancy that shows neoplastic proliferation of erythroid precursors with maturation arrest and no significant myeloblasts. We describe an autopsy case of this rare entity in a 62-year-old man with co-morbidities. He underwent a bone marrow (BM) examination for pancytopenia during the first outpatient department visit, which revealed an increased number of erythroid precursors with dysmegakaryopoiesis suggesting the possibility of Myelodysplastic syndromes (MDS). Thereafter, his cytopenia got worsened, warranting blood and platelet transfusions. Four weeks later on the second BM examination, AEL was diagnosed based on morphology and immunophenotyping. Targeted resequencing for myeloid mutations revealed TP53 and DNMT3A mutations. He was initially managed along febrile neutropenia with the stepwise escalation of antibiotics. He developed hypoxia attributed to anemic heart failure. Subsequently, he had hypotension and respiratory fatigue pre-terminally and succumbed to his Illness. A complete autopsy showed infiltration of various organs by AEL and leukostasis. Besides, there was extramedullary hematopoiesis, arterionephrosclerosis, diabetic nephropathy (ISN-RPS class II), mixed dust pneumoconiosis, and pulmonary arteriopathy. The histomorphology of AEL was challenging, and the differential diagnoses were many. Thus, this case highlights the autopsy pathology of AEL, an uncommon entity with a strict definition, and its relevant differentials.
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Affiliation(s)
- Mayur Parkhi
- Postgraduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Nabhajit Mallik
- Postgraduate Institute of Medical Education and Research, Department Hematology, Chandigarh, India
| | - Deepesh Lad
- Postgraduate Institute of Medical Education and Research, Department of Clinical Hematology and Medical Oncology, Chandigarh, India
| | | | - Amanjit Bal
- Postgraduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Pankaj Malhotra
- Postgraduate Institute of Medical Education and Research, Department of Clinical Hematology and Medical Oncology, Chandigarh, India
| | - Suvradeep Mitra
- Postgraduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
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5
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Hasserjian RP, Orazi A, Orfao A, Rozman M, Wang SA. The International Consensus Classification of myelodysplastic syndromes and related entities. Virchows Arch 2023; 482:39-51. [PMID: 36287260 DOI: 10.1007/s00428-022-03417-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The International Consensus Classification (ICC) of myeloid neoplasms and acute leukemia has updated the classification of myelodysplastic syndromes (MDSs) and placed MDS in a broader group of clonal cytopenias that includes clonal cytopenia of undetermined significance (CCUS) and related entities. Although subject to some interobserver variability and lack of specificity, morphologic dysplasia remains the main feature that distinguishes MDS from other clonal cytopenias and defines MDS as a hematologic malignancy. The ICC has introduced some changes in the definition of MDS whereby some cases categorized as MDS based on cytogenetic abnormalities are now classified as CCUS, while SF3B1 and multi-hit TP53 mutations are now considered to be MDS-defining in a cytopenic patient. The ICC has also recognized several cytogenetic and molecular abnormalities that reclassify some cases of MDS with excess blasts as acute myeloid leukemia (AML) and has introduced a new MDS/AML entity that encompasses cases with 10-19% blasts that lie on the continuum between MDS and AML. Two new genetically defined categories of MDS have been introduced: MDS with mutated SF3B1 and MDS with mutated TP53, the latter requiring bi-allelic aberrations in the TP53 gene. The entity MDS, unclassifiable has been eliminated. These changes have resulted in an overall simplification of the MDS classification scheme from 8 separate entities (including 1 that was genetically defined) in the revised 4th edition WHO classification to 7 separate entities (including 3 that are genetically defined) in the ICC.
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Affiliation(s)
- Robert P Hasserjian
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Warren 244, Boston, MA, 02114, USA.
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alberto Orfao
- Department of Medicine, Cytometry Service, Cancer Research Center (IBMCC-CSIC/USAL), Institute for Biomedical Research of Salamanca (IBSAL) and CIBERONC, University of Salamanca, Salamanca, Spain
| | - Maria Rozman
- Hematopathology Section, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Sa A Wang
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX, USA
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6
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Fang H, Wang SA, You MJ, Hu S, Miranda RN, Tang Z, Lin P, Jorgensen JL, Xu J, Thakral B, Schlette EJ, El Hussein S, Bueso-Ramos C, Medeiros LJ, Wang W. Flow cytometry immunophenotypic features of pure erythroid leukemia and the distinction from reactive erythroid precursors. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2022; 102:440-447. [PMID: 36156384 DOI: 10.1002/cyto.b.22095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 08/02/2022] [Accepted: 09/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The immunophenotype of pure erythroid leukemia (PEL) as determined by flow cytometry immunophenotypic analysis is not well characterized. The immunophenotypic difference between PEL and reactive conditions is under-explored. METHODS We assessed and compared the immunophenotype of 24 PEL cases and 28 reactive cases containing early erythroid precursors by flow cytometry. RESULTS The neoplastic erythroid cells in all PEL cases were positive for CD36 and CD71. CD45 was also positive in all cases, but the expression level was often dimmer than granulocytes. CD117 expression ranged from partial to uniform, and CD235a was often only positive in the CD117-dim to negative cells, corresponding to more differentiated subset. PEL cases frequently (87%) showed decreased or negative CD38 expression, contrasting to reactive early erythroid precursors that showed bright CD38 (p < 0.0001). CD7 (25%) and CD13 (29%) aberrant expressions were only observed in PEL but not in the reactive erythroid cells. Normal early erythroid precursors in all reactive bone marrows showed partial expression of CD4; In contrast, aberrant CD4 expression was detected in 71% PEL cases, either uniformly positive (50%) or completely negative (21%). While normal/reactive bone marrows almost always contained a small subset of CD34-positive early erythroid precursors, the neoplastic pronormoblasts in all PEL cases were CD34 negative. Although not increased in number, CD34-positive myeloblasts were frequently detected in PEL and demonstrated an aberrant immunophenotype in 90% PEL cases. CONCLUSIONS PEL shows a distinctive immunophenotype which can be distinguished from reactive erythroid precursors by flow cytometry immunophenotyping.
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Affiliation(s)
- Hong Fang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M James You
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shimin Hu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roberto N Miranda
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zhenya Tang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pei Lin
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jie Xu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Beenu Thakral
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ellen J Schlette
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Siba El Hussein
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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7
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The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours: Myeloid and Histiocytic/Dendritic Neoplasms. Leukemia 2022; 36:1703-1719. [PMID: 35732831 PMCID: PMC9252913 DOI: 10.1038/s41375-022-01613-1] [Citation(s) in RCA: 1155] [Impact Index Per Article: 577.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/20/2022] [Indexed: 12/19/2022]
Abstract
The upcoming 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid Tumours is part of an effort to hierarchically catalogue human cancers arising in various organ systems within a single relational database. This paper summarizes the new WHO classification scheme for myeloid and histiocytic/dendritic neoplasms and provides an overview of the principles and rationale underpinning changes from the prior edition. The definition and diagnosis of disease types continues to be based on multiple clinicopathologic parameters, but with refinement of diagnostic criteria and emphasis on therapeutically and/or prognostically actionable biomarkers. While a genetic basis for defining diseases is sought where possible, the classification strives to keep practical worldwide applicability in perspective. The result is an enhanced, contemporary, evidence-based classification of myeloid and histiocytic/dendritic neoplasms, rooted in molecular biology and an organizational structure that permits future scalability as new discoveries continue to inexorably inform future editions.
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8
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Torrez M, Chabot-Richards D, Babu D, Lockhart E, Foucar K. How I investigate acquired megaloblastic anemia. Int J Lab Hematol 2022; 44:236-247. [PMID: 34981651 DOI: 10.1111/ijlh.13789] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/20/2021] [Indexed: 12/01/2022]
Abstract
In this review of megaloblastic anemia (MA), an overview of vitamin B12 and folate body requirements, biochemical pathways, and laboratory testing strategies will be provided. However, the focus of this review is the classic and unique features of MA in blood and bone marrow. Acquired MA is a benign disorder for many, but can be detrimental for some. The clinical presentation can vary considerably, and the spectrum of symptoms and signs is diverse and quite broad. Prompt recognition and therapy are critical to prevent potential irreversible damage and clinical sequelae, especially in patients with vitamin B12 deficiency. A delay in diagnosis of vitamin B12 deficiency can result in significant neurologic sequelae that may not fully resolve with treatment, including in neonates and young infants. The blood and bone marrow features in MA can closely mimic thrombocytopenic purpura, myelodysplasia, and other myeloid neoplasms. Both pancytopenia and normal MCV at presentation are common in MA and raise unique challenges for the diagnostician. Partially treated MA is also a significant diagnostic "trap". MA is highly responsive to treatment, and patients tend to improve rapidly upon treatment initiation. However, the broad range of clinical and hematologic features makes the rapid, successful diagnosis of MA a unique challenge for the hematopathologist. Even in the era of state-of-the-art laboratory testing, a high suspicion is required.
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Affiliation(s)
- Mary Torrez
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Devon Chabot-Richards
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Daniel Babu
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Evelyn Lockhart
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Kathryn Foucar
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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9
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A rare de novo pure erythroid leukemia with JAK2 R683S mutation. Ann Hematol 2021; 101:921-922. [PMID: 34480614 DOI: 10.1007/s00277-021-04657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
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10
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Kasinathan G, Lee BS. Coexistence of myelodysplastic syndrome and acute megakaryoblastic leukemia: An aggressive disease. Clin Case Rep 2021; 9:e04156. [PMID: 34194755 PMCID: PMC8222645 DOI: 10.1002/ccr3.4156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 11/22/2022] Open
Abstract
Coexistent myelodysplastic syndrome and acute megakaryoblastic leukemia is an aggressive disease which often do not respond to standard chemotherapy due to the various molecular and cytogenetic abnormalities. Understanding of the molecular pathogenesis may lead to better therapeutic modalities as current conventional therapies are largely ineffective.
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Affiliation(s)
- Ganesh Kasinathan
- Department of HematologyAmpang HospitalJalan Mewah UtaraSelangorMalaysia
| | - Bee Sun Lee
- Department of HematologyAmpang HospitalJalan Mewah UtaraSelangorMalaysia
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11
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Acute erythroid leukemia is enriched in NUP98 fusions: a report from the Children's Oncology Group. Blood Adv 2021; 4:6000-6008. [PMID: 33284945 DOI: 10.1182/bloodadvances.2020002712] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022] Open
Abstract
Acute erythroid leukemia (AEL) is a rare subtype of acute myeloid leukemia (AML) primarily affecting older adults and was previously classified into erythroid/myeloid and pure erythroid subtypes. In this pediatric AEL study, we evaluated morphologic, immunophenotypic, cytogenetic, molecular, and clinical data of 24 (1.2%) cases from all cases undergoing central pathology review in Children's Oncology Group trials AAML0531 and AAML1031. Of 24 cases, 5 had a pure erythroid phenotype, and 19 had an erythroid/myeloid phenotype. NUP98 fusions were highly enriched in patients with AEL, occurring in 7 of 22 cases for which molecular data were available (31.8% vs 6.7% in other AML subtypes). Of 5 cases of pure erythroid leukemias (PELs), 3 had NUP98 fusions, and 4 had complex karyotypes. Erythroid/myeloid leukemias were reclassified by using the 2017 World Health Organization hematopathology classification as: myelodysplastic syndrome (MDS) with excess blasts-1 (n = 3), MDS with excess blasts-2 (n = 7), AML (nonerythroid, n = 5), and unknown MDS/AML (n = 4); the 5 cases of nonerythroid AML included 1 with an NUP98-NSD1 fusion, 2 with myelodysplasia-related changes, and 1 with a complex karyotype. Three cases of MDS with excess blasts-2 also had NUP98 rearrangements. WT1 mutations were present in 5 of 14 cases, all erythroid/myeloid leukemia. Outcomes assessment revealed statistically poorer overall survival (5-year, 20% ± 36% vs 66% ± 23%; P = .004) and event-free survival (5-year, 20% ± 36% vs 46% ± 23%; P = .019) for those with PEL than those with erythroid/myeloid leukemia. Our study supports that AEL is a morphologically and genetically heterogeneous entity that is enriched in NUP98 fusions, with the pure erythroid subtype associated with particularly adverse outcomes.
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12
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Di Genua C, Nerlov C. To bi or not to bi: Acute erythroid leukemias and hematopoietic lineage choice. Exp Hematol 2021; 97:6-13. [PMID: 33600869 DOI: 10.1016/j.exphem.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
Acute erythroid leukemia (AEL) is an acute leukemia characterized by erythroid lineage transformation. The World Health Organization (WHO) 2008 classification recognized two subtypes of AEL: bilineage erythroleukemia (erythroid/myeloid leukemia) and pure erythroid leukemia. The erythroleukemia subtype was removed in the updated 2016 WHO classification, with about half of cases reclassified as myelodysplastic syndrome (MDS) and half as acute myeloid leukemia (AML). Diagnosis and classification are currently based on morphology using standard blast cutoffs, without integration of underlying genomic and other molecular features. Key outstanding questions are therefore whether AEL can be accurately diagnosed based solely on morphology or whether genetic or other molecular criteria should be included in its classification, and whether considering AEL as an entity distinct from AML and MDS is clinically relevant. We discuss recent work on the molecular basis of AEL, including the identification of mutations causative of AEL and of transcriptional and epigenetic features that can be used to distinguish AEL from MDS and nonerythroid AML, and the prognostic value of these molecular features.
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MESH Headings
- Animals
- Epigenesis, Genetic
- Erythroid Cells/metabolism
- Erythroid Cells/pathology
- Gene Expression Regulation, Leukemic
- Humans
- Leukemia, Erythroblastic, Acute/diagnosis
- Leukemia, Erythroblastic, Acute/genetics
- Leukemia, Erythroblastic, Acute/pathology
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Mutation
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/genetics
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Affiliation(s)
- Cristina Di Genua
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, UK
| | - Claus Nerlov
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, UK.
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13
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Characteristics and outcomes of therapy-related myeloid neoplasms following autologous stem cell transplantation for multiple myeloma. Blood Cancer J 2021; 11:63. [PMID: 33741897 PMCID: PMC7979889 DOI: 10.1038/s41408-021-00454-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/14/2022] Open
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14
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Alexandres C, Basha B, King RL, Howard MT, Reichard KK. p53 immunohistochemistry discriminates between pure erythroid leukemia and reactive erythroid hyperplasia. J Hematop 2021. [DOI: 10.1007/s12308-020-00431-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AbstractPure erythroid leukemia (PEL) is a rare, aggressive subtype of acute myeloid leukemia with a poor prognosis. The diagnosis of PEL is often medically urgent, quite challenging, and is typically a diagnosis of exclusion requiring meticulous distinction from non-neoplastic erythroid proliferations, particularly florid erythroid hyperplasia/regeneration. Given the frequency of TP53 mutations in the molecular signature of PEL, we hypothesize that differential p53 expression by immunohistochemistry (IHC) may be useful in distinguishing PEL versus non-neoplastic erythroid conditions. We performed p53 IHC on 5 normal bone marrow, 46 reactive erythroid proliferations, and 27 PEL cases. We assessed the positivity and intensity of nuclear staining in pronormoblasts and basophilic normoblasts using a 0–3+ scale with 0 being absent (with internal positive controls) and 3 being strong nuclear positivity. A total of 26/27 PEL cases showed strong, uniform, diffuse intense staining by the neoplastic pronormoblasts versus 0/5 and 0/46 normal and reactive controls, respectively. The control cases show various staining patterns ranging from 0 to 3+ in scattered erythroid precursor cells. Uniform, strong p53 positivity is unique to PEL and discriminates this entity from a benign erythroid mimic. Thus, p53 IHC may be a useful marker in urgent medical cases to assist in the confirmation of a malignant PEL diagnosis while awaiting the results of additional ancillary studies such as cytogenetics.
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15
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Yanagisawa R, Kato M, Sakaguchi K, Nakagoshi R, Ogiso Y, Fukushima K, Sakashita K. A case of pure erythroid leukemia with MYB-GATA1 fusion that developed tumor lysis syndrome with dexamethasone. Pediatr Blood Cancer 2020; 67:e28285. [PMID: 32634254 DOI: 10.1002/pbc.28285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ryu Yanagisawa
- Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan.,Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan.,Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | - Motohiro Kato
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimiyoshi Sakaguchi
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ritsuko Nakagoshi
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Yoshifumi Ogiso
- Department of Laboratory Medicine, Nagano Children's Hospital, Azumino, Japan
| | - Keitaro Fukushima
- Department of Pediatrics, Dokkyo Medical University, Shimotsuga, Japan
| | - Kazuo Sakashita
- Department of Hematology/Oncology, Nagano Children's Hospital, Azumino, Japan
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16
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Fagnan A, Bagger FO, Piqué-Borràs MR, Ignacimouttou C, Caulier A, Lopez CK, Robert E, Uzan B, Gelsi-Boyer V, Aid Z, Thirant C, Moll U, Tauchmann S, Kurtovic-Kozaric A, Maciejewski J, Dierks C, Spinelli O, Salmoiraghi S, Pabst T, Shimoda K, Deleuze V, Lapillonne H, Sweeney C, De Mas V, Leite B, Kadri Z, Malinge S, de Botton S, Micol JB, Kile B, Carmichael CL, Iacobucci I, Mullighan CG, Carroll M, Valent P, Bernard OA, Delabesse E, Vyas P, Birnbaum D, Anguita E, Garçon L, Soler E, Schwaller J, Mercher T. Human erythroleukemia genetics and transcriptomes identify master transcription factors as functional disease drivers. Blood 2020; 136:698-714. [PMID: 32350520 PMCID: PMC8215330 DOI: 10.1182/blood.2019003062] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 03/25/2020] [Indexed: 12/11/2022] Open
Abstract
Acute erythroleukemia (AEL or acute myeloid leukemia [AML]-M6) is a rare but aggressive hematologic malignancy. Previous studies showed that AEL leukemic cells often carry complex karyotypes and mutations in known AML-associated oncogenes. To better define the underlying molecular mechanisms driving the erythroid phenotype, we studied a series of 33 AEL samples representing 3 genetic AEL subgroups including TP53-mutated, epigenetic regulator-mutated (eg, DNMT3A, TET2, or IDH2), and undefined cases with low mutational burden. We established an erythroid vs myeloid transcriptome-based space in which, independently of the molecular subgroup, the majority of the AEL samples exhibited a unique mapping different from both non-M6 AML and myelodysplastic syndrome samples. Notably, >25% of AEL patients, including in the genetically undefined subgroup, showed aberrant expression of key transcriptional regulators, including SKI, ERG, and ETO2. Ectopic expression of these factors in murine erythroid progenitors blocked in vitro erythroid differentiation and led to immortalization associated with decreased chromatin accessibility at GATA1-binding sites and functional interference with GATA1 activity. In vivo models showed development of lethal erythroid, mixed erythroid/myeloid, or other malignancies depending on the cell population in which AEL-associated alterations were expressed. Collectively, our data indicate that AEL is a molecularly heterogeneous disease with an erythroid identity that results in part from the aberrant activity of key erythroid transcription factors in hematopoietic stem or progenitor cells.
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Affiliation(s)
- Alexandre Fagnan
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Frederik Otzen Bagger
- University Children's Hospital Beider Basel (UKBB), Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
- Center for Genomic Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Swiss Institute of Bioinformatics, Basel, Basel, Switzerland
| | - Maria-Riera Piqué-Borràs
- University Children's Hospital Beider Basel (UKBB), Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Cathy Ignacimouttou
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Alexis Caulier
- Equipe d'Accueil (EA) 4666, Hématopoïèse et Immunologie (HEMATIM), Université de Picardie Jules Verne (UPJV), Amiens, France
- Service Hématologie Biologique, Centre Hospitalier Universitaire (CHU) Amiens, Amiens, France
| | - Cécile K Lopez
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Elie Robert
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Benjamin Uzan
- Unité Mixte de Recherche 967 (UMR 967), INSERM-Commissariat à l'Énergie Atomique et aux Énergies Alternatives (CEA)/Direction de la Recherche Fondamentale (DRF)/Institut de Biologie François Jacob (IBFJ)/Institut de Radiobiologie Cellulaire et Moléculaire (IRCM)/Laboratoire des cellules Souches Hématopoïétiques et des Leucémies (LSHL)-Université Paris-Diderot-Université Paris-Sud, Fontenay-aux-Roses, France
| | - Véronique Gelsi-Boyer
- U1068 and
- UMR7258, Centre de Recherche en Cancérologie de Marseille, Centre National de la Recherche Scientifique (CNRS)/INSERM/Institut Paoli Calmettes/Aix-Marseille Université, Marseille, France
| | - Zakia Aid
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Cécile Thirant
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Ute Moll
- Institute of Molecular Oncology, University Medical Center Göttingen, Göttingen, Germany
- Department of Pathology, Stony Brook University, Stony Brook, NY
| | - Samantha Tauchmann
- University Children's Hospital Beider Basel (UKBB), Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Amina Kurtovic-Kozaric
- Clinical Center of the University of Sarajevo, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Jaroslaw Maciejewski
- Department of Translational Hematology and Oncologic Research, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Christine Dierks
- Hämatologie, Onkologie und Stammzelltransplantation, Klinik für Innere Medizin I, Freiburg, Germany
| | - Orietta Spinelli
- UOC Ematologia, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Silvia Salmoiraghi
- UOC Ematologia, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII Hospital, Bergamo, Italy
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Pabst
- Department of Oncology, Inselspital, University Hospital Bern/University of Bern, Bern, Switzerland
| | - Kazuya Shimoda
- Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Virginie Deleuze
- IGMM, University of Montpellier, CNRS, Montpellier, France
- Université de Paris, Laboratory of Excellence GR-Ex, Paris, France
| | - Hélène Lapillonne
- Centre de Recherche Saint Antoine (CRSA)-Unité INSERM, Sorbonne Université/Assistance Publique-Hôpitaux de Paris (AP-HP)/Hôpital Trousseau, Paris, France
| | - Connor Sweeney
- Medical Research Council Molecular Haematology Unit (MRC MHU), Biomedical Research Centre (BRC) Hematology Theme, Oxford Biomedical Research Centre, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine (WIMM), Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Véronique De Mas
- Team 16, Hematology Laboratory, Center of Research of Cancerology of Toulouse, U1037, INSERM/Institut Universitaire du Cancer de Toulouse (IUCT) Oncopole, Toulouse, France
| | - Betty Leite
- Genomic Platform, Unité Mixte de Service - Analyse Moléculaire, Modélisation et Imagerie de la maladie Cancéreuse (UMS AMMICA), Gustave Roussy/Université Paris-Saclay, Villejuif, France
| | - Zahra Kadri
- Division of Innovative Therapies, UMR-1184, Immunologie des Maladies Virales, Auto-immunes, Hématologiques et Bactériennes (IMVA-HB) and Infectious Disease Models and Innovative Therapies (IDMIT) Center, CEA/INSERM/Paris-Saclay University, Fontenay-aux-Roses, France
| | - Sébastien Malinge
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Telethon Kids Institute, Perth Children's Hospital, Nedlands, WA, Australia
| | - Stéphane de Botton
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Jean-Baptiste Micol
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
| | - Benjamin Kile
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | | | - Ilaria Iacobucci
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN
| | - Martin Carroll
- Division of Hematology and Oncology, University of Pennsylvania, PA
| | - Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I and
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Olivier A Bernard
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
| | - Eric Delabesse
- Team 16, Hematology Laboratory, Center of Research of Cancerology of Toulouse, U1037, INSERM/Institut Universitaire du Cancer de Toulouse (IUCT) Oncopole, Toulouse, France
| | - Paresh Vyas
- Medical Research Council Molecular Haematology Unit (MRC MHU), Biomedical Research Centre (BRC) Hematology Theme, Oxford Biomedical Research Centre, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine (WIMM), Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Daniel Birnbaum
- U1068 and
- UMR7258, Centre de Recherche en Cancérologie de Marseille, Centre National de la Recherche Scientifique (CNRS)/INSERM/Institut Paoli Calmettes/Aix-Marseille Université, Marseille, France
| | - Eduardo Anguita
- Hematology Department
- Instituto de Medicina de Laboratorio (IML), and
- Instituto de Investigación Sanitaria San Carlos, (IdISSC), Hospital Clínico San Carlos (HCSC), Madrid, Spain; and
- Department of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Loïc Garçon
- Equipe d'Accueil (EA) 4666, Hématopoïèse et Immunologie (HEMATIM), Université de Picardie Jules Verne (UPJV), Amiens, France
- Service Hématologie Biologique, Centre Hospitalier Universitaire (CHU) Amiens, Amiens, France
| | - Eric Soler
- IGMM, University of Montpellier, CNRS, Montpellier, France
- Université de Paris, Laboratory of Excellence GR-Ex, Paris, France
| | - Juerg Schwaller
- University Children's Hospital Beider Basel (UKBB), Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Thomas Mercher
- Unité 1170 (U1170), INSERM, Gustave Roussy, Université Paris Diderot, Villejuif, France
- Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
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17
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Sas V, Blag C, Zaharie G, Puscas E, Lisencu C, Andronic-Gorcea N, Pasca S, Petrushev B, Chis I, Marian M, Dima D, Teodorescu P, Iluta S, Zdrenghea M, Berindan-Neagoe I, Popa G, Man S, Colita A, Stefan C, Kojima S, Tomuleasa C. Transient leukemia of Down syndrome. Crit Rev Clin Lab Sci 2019; 56:247-259. [PMID: 31043105 DOI: 10.1080/10408363.2019.1613629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Childhood leukemia is mostly a "developmental accident" during fetal hematopoiesis and may require multiple prenatal and postnatal "hits". The World Health Organization defines transient leukemia of Down syndrome (DS) as increased peripheral blood blasts in neonates with DS and classifies this type of leukemia as a separate entity. Although it was shown that DS predisposes children to myeloid leukemia, neither the nature of the predisposition nor the associated genetic lesions have been defined. Acute myeloid leukemia of DS is a unique disease characterized by a long pre-leukemic, myelodysplastic phase, unusual chromosomal findings and a high cure rate. In the present manuscript, we present a comprehensive review of the literature about clinical and biological findings of transient leukemia of DS (TL-DS) and link them with the genetic discoveries in the field. We address the manuscript to the pediatric generalist and especially to the next generation of pediatric hematologists.
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Affiliation(s)
- Valentina Sas
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania.,b Department of Pediatrics , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Cristina Blag
- b Department of Pediatrics , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Gabriela Zaharie
- c Department of Neonatology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Emil Puscas
- d Department of Surgery , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Cosmin Lisencu
- d Department of Surgery , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Nicolae Andronic-Gorcea
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Sergiu Pasca
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Bobe Petrushev
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Irina Chis
- e Department of Physiology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mirela Marian
- f Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Delia Dima
- f Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Patric Teodorescu
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Sabina Iluta
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mihnea Zdrenghea
- f Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Ioana Berindan-Neagoe
- g MedFuture Research Center for Advanced Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Gheorghe Popa
- b Department of Pediatrics , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Sorin Man
- b Department of Pediatrics , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Anca Colita
- h Department of Pediatrics , Carol Davila University of Medicine and Pharmacy , Bucharest , Romania.,i Department of Pediatrics , Fundeni Clinical Institute , Bucharest , Romania
| | - Cristina Stefan
- j African Organization for Research and Training in Cancer , Cape Town , South Africa
| | - Seiji Kojima
- k Department of Pediatrics , Nagoya University Graduate School of Medicine , Nagoya , Japan.,l Center for Advanced Medicine and Clinical Research , Nagoya University Hospital , Nagoya , Japan
| | - Ciprian Tomuleasa
- a Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania.,f Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania.,m Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
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18
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Medford A, Brunner A, Nardi V, Hasserjian R, Carlson J, Choy E. Therapy-Related Erythroleukemia in a Man With Metastatic Ewing Sarcoma: A Clinical Role for Advanced Molecular Diagnostics. JCO Precis Oncol 2018; 2:1-6. [PMID: 35135116 DOI: 10.1200/po.17.00217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Arber DA. The 2016 WHO classification of acute myeloid leukemia: What the practicing clinician needs to know. Semin Hematol 2018; 56:90-95. [PMID: 30926096 DOI: 10.1053/j.seminhematol.2018.08.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/31/2018] [Accepted: 08/13/2018] [Indexed: 01/11/2023]
Abstract
In 2016 a revision of the World Health Organization (WHO) classification of acute myeloid leukemia (AML) was introduced that included changes to several disease categories. The WHO approach results in disease categories that are defined by a combination of clinical, morphologic, immunophenotypic, and genetic features in an attempt to define clinically relevant, biologic entities. This review summarizes the WHO approach as well as the priority of specific features for disease classification. Changes to specific categories, including AML with myelodysplasia-related changes, AML with mutated NPM1, AML with biallelic mutations of CEBPA and erythroleukemia are summarized. The importance of additional gene mutations as well as germline predisposition in AML is also reviewed.
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Affiliation(s)
- Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL.
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20
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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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21
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Xiao W, Rampal R, Zhang Y, Cimera R, Jungbluth AA, Arcila M, Roshal M, Park DC. JAK/MAP kinase pathway activation and TP53 mutations in acute leukemia with megakaryocytic and erythroid differentiation. Leukemia 2018; 32:1842-1845. [PMID: 29743724 DOI: 10.1038/s41375-018-0145-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Wenbin Xiao
- Hematopathology Diagnostic Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Raajit Rampal
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yanming Zhang
- Cytogenetic Laboratory, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert Cimera
- Cytogenetic Laboratory, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Achim A Jungbluth
- Hematopathology Diagnostic Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Arcila
- Diagnostic Molecular Laboratory, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Hematopathology Diagnostic Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David C Park
- Hematopathology Diagnostic Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pathology, Columbia University Medical Center, New York, NY, USA
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22
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Molecular evidence of JAK2 p.V617F mutated pure erythroid leukemia arising from polycythemia vera. Virchows Arch 2018; 473:131-135. [PMID: 29611054 DOI: 10.1007/s00428-018-2347-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/14/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
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23
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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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25
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Liang X, Kong P, Wang J, Xu Y, Gao C, Guo G. Effects of metformin on proliferation and apoptosis of human megakaryoblastic Dami and MEG-01 cells. J Pharmacol Sci 2017; 135:14-21. [PMID: 28927780 DOI: 10.1016/j.jphs.2017.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/11/2017] [Accepted: 08/02/2017] [Indexed: 01/07/2023] Open
Abstract
Metformin has received increasing attention for its potential anticancer activity against certain human leukemia cells, but its effects on human megakaryoblastic cells are unclear. This study aimed to investigate the effects of metformin on proliferation and apoptosis of human megakaryoblastic cells (Dami and MEG-01) and the underlying molecular mechanisms. CCK8 assay was employed to measure cell proliferation. Flow cytometry was adopted to detect cell apoptosis. Western blot was further employed to measure apoptosis-related proteins. In Dami and MEG-01 cells, metformin significantly inhibited proliferation and promoted apoptosis in a dose- and time-dependent manner, and metformin (4 mM) was selected for subsequent experiments. Metformin inhibited ERK1/2, JNK, and PI3K/Akt, but activated p38 pathway in these two cells. Moreover, inhibition of ERK1/2, JNK or PI3K/Akt pathway alone induced cell apoptosis compared to the control group. The combination of specific inhibitors of ERK1/2, JNK or PI3K/Akt pathway and metformin further promoted cell apoptosis and the up-regulation of p21, Bax, Bad, cleaved caspase-3 and -9 as well as the down-regulation of Bcl-2 mediated by metformin alone, but inhibition of p38 pathway exhibited the opposite results. These findings support the possibility of metformin treatment as a new therapeutic strategy against acute megakaryoblastic leukemia (AMKL).
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Affiliation(s)
- Xue Liang
- Department of Hematology, No. 150 Central Hospital of Chinese People's Liberation Army, Luoyang, China
| | - Peiyan Kong
- Department of Hematology, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Jin Wang
- Department of Hematology, No. 150 Central Hospital of Chinese People's Liberation Army, Luoyang, China
| | - Yulin Xu
- Department of Hematology, No. 150 Central Hospital of Chinese People's Liberation Army, Luoyang, China
| | - Chunfang Gao
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of Chinese People's Liberation Army, No. 2 Huaxia Road, Luoyang, 471000, China.
| | - Guozhen Guo
- Department of Radiation Medicine, School of Public Health, The Fourth Military Medical University, No. 169 Changle West Road, Xi'an, 710032, China.
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26
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Park DC, Ozkaya N, Lovitch SB. Acute leukaemia with a pure erythroid phenotype: under-recognized morphological and cytogenetic signatures associated universally with primary refractory disease and a dismal clinical outcome. Histopathology 2017; 71:316-321. [DOI: 10.1111/his.13207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- David C Park
- Department of Pathology; Memorial Sloan Kettering Cancer Center; New York NY USA
| | - Neval Ozkaya
- Department of Pathology; Memorial Sloan Kettering Cancer Center; New York NY USA
| | - Scott B Lovitch
- Department of Pathology; Brigham and Women's Hospital; Boston MA USA
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27
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Wang W, Wang SA, Medeiros LJ, Khoury JD. Pure erythroid leukemia. Am J Hematol 2017; 92:292-296. [PMID: 28006859 DOI: 10.1002/ajh.24626] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/14/2016] [Indexed: 02/01/2023]
Abstract
The category of acute erythroid leukemia was significantly revised in the recently published 2016 revision to the World Health Organization (WHO) classification of myeloid neoplasms. In the previous 2008 WHO classification, acute erythroid leukemia was categorized into two subtypes: erythroleukemia and pure erythroid leukemia (PEL), whereas in the 2016 WHO update, erythroleukemia was merged into myelodysplastic syndrome, and PEL becomes the only type of acute erythroid leukemia. PEL is a rare and aggressive form of acute leukemia whose biology remains poorly characterized. In this review, we discuss the clinicopathologic features, diagnosis, putative pathogenesis, and molecular biology of PEL, with an overview of novel concepts and future directions in this area.
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Affiliation(s)
- Wei Wang
- Departments of HematopathologyThe University of Texas MD Anderson Cancer CenterHouston Texas USA
| | - Sa A. Wang
- Departments of HematopathologyThe University of Texas MD Anderson Cancer CenterHouston Texas USA
| | - L. Jeffrey Medeiros
- Departments of HematopathologyThe University of Texas MD Anderson Cancer CenterHouston Texas USA
| | - Joseph D. Khoury
- Departments of HematopathologyThe University of Texas MD Anderson Cancer CenterHouston Texas USA
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28
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Wang SA, Patel KP, Pozdnyakova O, Peng J, Zuo Z, Dal Cin P, Steensma DP, Hasserjian RP. Acute erythroid leukemia with <20% bone marrow blasts is clinically and biologically similar to myelodysplastic syndrome with excess blasts. Mod Pathol 2016; 29:1221-31. [PMID: 27443511 DOI: 10.1038/modpathol.2016.118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/11/2016] [Accepted: 05/29/2016] [Indexed: 11/09/2022]
Abstract
In acute erythroleukemia, erythroid/myeloid subtype, blasts usually comprise 5-19% of total bone marrow cells, similar to the myelodysplastic syndrome subtype refractory anemia with excess blasts; recent studies have raised the question if acute erythroleukemia should be considered as a myelodysplastic syndrome subtype. We reviewed 77 de novo acute erythroleukemia and 279 de novo refractory anemia with excess blasts from three large medical centers. Compared to refractory anemia with excess blasts, acute erythroleukemia patients had higher total bone marrow blasts, lower platelets, hemoglobin, and absolute neutrophil counts, with more patients being assigned a very-poor-karyotype risk and very-high Revised International Prognostic Scoring System score. Induction chemotherapy was administered to 55% of acute erythroleukemia patients, but was not associated with longer overall survival compared to acute erythroleukemia patients treated with lower-intensity therapies or supportive care (P=0.44). In multivariable analysis of all patients, Revised International Prognostic Scoring System very high (P<0.0001) or high (P=0.005) risk, but not a diagnosis of acute erythroleukemia (P=0.30), were independent risk factors for shorter overall survival. Our data show that acute erythroleukemia patients have similar risk-adjusted outcome to refractory anemia with excess blasts patients and do not appear to gain survival advantage with acute myeloid leukemia-type induction chemotherapy. These data suggest that acute erythroleukemia, erythroid/myeloid subtype with <20% blasts may be more appropriately classified as refractory anemia with excess blasts rather than as an acute myeloid leukemia subtype.
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Affiliation(s)
- Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jie Peng
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhuang Zuo
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paola Dal Cin
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - David P Steensma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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29
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Helin H, van der Walt J, Holder M, George S. Case Report: Congenital Erythroleukemia in a Premature Infant with Dysmorphic Features. Pediatr Dev Pathol 2016; 19:334-7. [PMID: 26529397 DOI: 10.2350/15-04-1625-cr.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present a case of pure erythroleukemia, diagnosed at autopsy, in a dysmorphic premature infant who died of multiorgan failure within 24 hours of birth. Dysmorphic features included facial and limb abnormalities with long philtrum, microagnathia, downturned mouth, short neck as well as abnormal and missing nails, missing distal phalanx from the second toe, and overlapping toes. Internal findings included gross hepatomegaly and patchy hemorrhages in the liver, splenomegaly, and cardiomegaly; and subdural, intracerebral, and intraventricular hemorrhages. Histology revealed infiltration of bone marrow, kidney, heart, liver, adrenal, lung, spleen, pancreas, thyroid, testis, thymus, and placenta by pure erythroleukemia. Only 6 cases of congenital erythroleukemia have been previously reported with autopsy findings similar to those of this case. The dysmorphic features, although not fitting any specific syndrome, make this case unique. Congenital erythroleukemia and possible syndromes suggested by the dysmorphic features are discussed.
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Affiliation(s)
- Heidi Helin
- 1 Department of Histopathology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Jon van der Walt
- 1 Department of Histopathology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Muriel Holder
- 2 Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond SE1 9RT, UK
| | - Simi George
- 1 Department of Histopathology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
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30
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The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 2016; 127:2391-405. [PMID: 27069254 DOI: 10.1182/blood-2016-03-643544] [Citation(s) in RCA: 6117] [Impact Index Per Article: 764.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023] Open
Abstract
The World Health Organization (WHO) classification of tumors of the hematopoietic and lymphoid tissues was last updated in 2008. Since then, there have been numerous advances in the identification of unique biomarkers associated with some myeloid neoplasms and acute leukemias, largely derived from gene expression analysis and next-generation sequencing that can significantly improve the diagnostic criteria as well as the prognostic relevance of entities currently included in the WHO classification and that also suggest new entities that should be added. Therefore, there is a clear need for a revision to the current classification. The revisions to the categories of myeloid neoplasms and acute leukemia will be published in a monograph in 2016 and reflect a consensus of opinion of hematopathologists, hematologists, oncologists, and geneticists. The 2016 edition represents a revision of the prior classification rather than an entirely new classification and attempts to incorporate new clinical, prognostic, morphologic, immunophenotypic, and genetic data that have emerged since the last edition. The major changes in the classification and their rationale are presented here.
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31
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Li H, Hasserjian RP, Kroft SH, Harrington AM, Wheaton SE, Pildain A, Ewalt MD, Gratzinger D, Hosking P, Olteanu H. Pure Erythroid Leukemia and Erythroblastic Sarcoma Evolving From Chronic Myeloid Neoplasms. Am J Clin Pathol 2016; 145:538-51. [PMID: 27124944 DOI: 10.1093/ajcp/aqw033] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pure erythroid leukemia (PEL) is an extremely rare entity that may, even more rarely, evolve from a preexisting chronic myeloid neoplasm (CMN); there is minimal literature regarding this latter phenomenon. METHODS We describe 14 patients with PEL that represented progression from a preexisting myelodysplastic syndrome (MDS, n = 8) or myeloproliferative neoplasm (MPN, n = 6), three of which manifested as erythroblastic sarcoma (EBS), a rare entity. These patients had a highly complex karyotype with prominent clonal evolution and a very aggressive clinical course. RESULTS Patients with PEL from MDS showed a more rapid progression time to PEL and had lower platelet counts compared with PEL from MPN. No other significant differences were found between the two groups. CONCLUSIONS These data represent the largest cohort of patients with PEL and an antecedent CMN, as well as the largest series of EBS reported to date, and underscore the unique morphologic, cytogenetic, immunophenotypic, and clinical features of this uncommon entity.
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Affiliation(s)
- Hongmei Li
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee
| | | | - Steven H Kroft
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee
| | | | | | - Alex Pildain
- Department of Pathology, Texas Health Presbyterian Hospital, Dallas
| | - Mark D Ewalt
- Department of Pathology, Stanford University, Stanford, CA
| | | | - Paul Hosking
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee
| | - Horatiu Olteanu
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee
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32
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Peng J, Hasserjian RP, Tang G, Patel KP, Goswami M, Jabbour EJ, Garcia-Manero G, Medeiros LJ, Wang SA. Myelodysplastic syndromes following therapy with hypomethylating agents (HMAs): development of acute erythroleukemia may not influence assessment of treatment response. Leuk Lymphoma 2016; 57:812-9. [PMID: 26293512 DOI: 10.3109/10428194.2015.1079318] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study followed 28 patients with myelodysplastic syndromes (MDS) who showed a rise of bone marrow (BM) erythroids to ≥ 50% following three cycles (1-60) of hypomethylating agent (HMA) therapy. If BM blasts were calculated as a percentage of non-erythroids, 12 (42.9%) patients met the diagnostic criteria for acute erythroleukemia, erythroid/myeloid (AEL). However, none of the patients showed clonal cytogenetic evolution or new mutations. When compared to 47 de novo AEL patients, these 12 patients were less anemic and thrombocytopenic, had less complex karyotypes (p = 0.044) and showed a longer survival, either calculated from diagnosis (p < 0.001) or from the time of AEL (p = 0.005). These findings illustrate that ≥ 50% erythroids may appear in BM post-HMA therapy, likely a combination of reduction of BM granulocytes (p < 0.001) and promotion of normal or abnormal erythroid proliferation. Enumeration of blasts as a percentage of non-erythroid cells may lead to a diagnosis of AEL and mis-interpretation as disease progression.
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Affiliation(s)
- Jie Peng
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Robert P Hasserjian
- b Department of Pathology , Massachusetts General Hospital , Boston , MA , USA
| | - Guilin Tang
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Keyur P Patel
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Maitrayee Goswami
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Elias J Jabbour
- c Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Guillermo Garcia-Manero
- c Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - L Jeffrey Medeiros
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Sa A Wang
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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