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Bawek SJ, Wang ES, Green SD. Acute leukemia with KMT2A rearrangement: A master of disguise. Leuk Res Rep 2024; 21:100464. [PMID: 38903873 PMCID: PMC11186854 DOI: 10.1016/j.lrr.2024.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/14/2024] [Indexed: 06/22/2024] Open
Abstract
Mixed-phenotype acute leukemia (MPAL) is a rare form of leukemia with ambiguous lineage, and there are challenges in accurately diagnosing this entity according to formal criteria. Here we report a case which was initially diagnosed as "AML" based on atypical peripheral blood flow cytometry that was subsequently determined to be B-ALL with KMT2A rearrangement based on marrow results. Although KMT2A rearrangements represent a defining genetic abnormality for acute leukemia of ambiguous lineage, this case did not meet the criteria for MPAL based on WHO 2022 criteria. This case highlights the diagnostic challenges of MPAL and the potential limitations of the current classification. We discuss the most appropriate workup and management of these patients and identify areas for future study.
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Affiliation(s)
- Sawyer J. Bawek
- Department of Internal Medicine, University at Buffalo, Buffalo, NY, United States
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Eunice S. Wang
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Steven D. Green
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
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Kaur A, Ramamurthy S, Amritham U, Gopal C, Kaushik PS, Rajanna AKA, Thumalapalli A, Bhat AKBS, Appaji L. Extramedullary mixed phenotypic (B/T) lymphoblastic lymphoma of scalp: A rare case with unique presentation. Pediatr Blood Cancer 2024; 71:e30875. [PMID: 38234015 DOI: 10.1002/pbc.30875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024]
Affiliation(s)
- Amrit Kaur
- Department of Pediatric Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Sindhu Ramamurthy
- Department of Pathology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Usha Amritham
- Department of Pathology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Champaka Gopal
- Department of Pathology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Prakruthi S Kaushik
- Department of Pediatric Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - Avinash Thumalapalli
- Department of Pediatric Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - Lingegowda Appaji
- Department of Pediatric Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
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He J, Munir F, Catueno S, Connors JS, Gibson A, Robusto L, McCall D, Nunez C, Roth M, Tewari P, Garces S, Cuglievan B, Garcia MB. Biological Markers of High-Risk Childhood Acute Lymphoblastic Leukemia. Cancers (Basel) 2024; 16:858. [PMID: 38473221 DOI: 10.3390/cancers16050858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
Childhood acute lymphoblastic leukemia (ALL) has witnessed substantial improvements in prognosis; however, a subset of patients classified as high-risk continues to face higher rates of relapse and increased mortality. While the National Cancer Institute (NCI) criteria have traditionally guided risk stratification based on initial clinical information, recent advances highlight the pivotal role of biological markers in shaping the prognosis of childhood ALL. This review delves into the emerging understanding of high-risk childhood ALL, focusing on molecular, cytogenetic, and immunophenotypic markers. These markers not only contribute to unraveling the underlying mechanisms of the disease, but also shed light on specific clinical patterns that dictate prognosis. The paradigm shift in treatment strategies, exemplified by the success of tyrosine kinase inhibitors in Philadelphia chromosome-positive leukemia, underscores the importance of recognizing and targeting precise risk factors. Through a comprehensive exploration of high-risk childhood ALL characteristics, this review aims to enhance our comprehension of the disease, offering insights into its molecular landscape and clinical intricacies in the hope of contributing to future targeted and tailored therapies.
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Affiliation(s)
- Jiasen He
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Faryal Munir
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Samanta Catueno
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jeremy S Connors
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Amber Gibson
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lindsay Robusto
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David McCall
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Cesar Nunez
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michael Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Priti Tewari
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sofia Garces
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Branko Cuglievan
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Miriam B Garcia
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Panagopoulos I, Andersen K, Johannsdottir IMR, Tandsæther MR, Micci F, Heim S. Genetic Characterization of Pediatric Mixed Phenotype Acute Leukemia (MPAL). Cancer Genomics Proteomics 2024; 21:1-11. [PMID: 38151288 PMCID: PMC10756350 DOI: 10.21873/cgp.20424] [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: 10/11/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND/AIM Mixed phenotype acute leukemia (MPAL) is a rare hematologic malignancy in which the leukemic cells cannot be assigned to any specific lineage. The lack of well-defined, pathogenetically relevant diagnostic criteria makes the clinical handling of MPAL patients challenging. We herein report the genetic findings in bone marrow cells from two pediatric MPAL patients. PATIENTS AND METHODS Bone marrow cells were examined using G-banding, array comparative genomic hybridization, RNA sequencing, reverse transcription polymerase chain reaction, Sanger sequencing, and fluorescence in situ hybridization. RESULTS In the first patient, the genetic analyses revealed structural aberrations of chromosomal bands 8p11, 10p11, 11q21, and 17p11, the chimeras MLLT10::PICALM and PICALM::MLLT10, and imbalances (gains/losses) on chromosomes 2, 4, 8, 13, and 21. A submicroscopic deletion in 21q was also found including the RUNX1 locus. In the second patient, there were structural aberrations of chromosome bands 1p32, 8p11, 12p13, 20p13, and 20q11, the chimeras ETV6::LEXM and NCOA6::ETV6, and imbalances on chromosomes 2, 8, 11, 12, 16, 19, X, and Y. CONCLUSION The leukemic cells from both MPAL patients carried chromosome aberrations resulting in fusion genes as well as genomic imbalances resulting in gain and losses of many gene loci. The detected fusion genes probably represent the main leukemogenic events, although the gains and losses are also likely to play a role in leukemogenesis.
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Affiliation(s)
- Ioannis Panagopoulos
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway;
| | - Kristin Andersen
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | | | - Maren Randi Tandsæther
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Francesca Micci
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Sverre Heim
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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Huang J, Feng B, Cheng Y, Xu L, Zhang X, Huang X, Wang Y. Unmanipulated haploidentical hematopoietic stem cell transplantation for mixed phenotype acute leukemia: a single center study. Bone Marrow Transplant 2024; 59:147-149. [PMID: 37903993 DOI: 10.1038/s41409-023-02141-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/14/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023]
Affiliation(s)
- Junbin Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Bo Feng
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
- Department of Hematology, Jiujiang First People's Hospital, Jiujiang, China
| | - Yifei Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking-Tsinghua Center for Life Science, Research Unit of Key Technique for Diagnosis and Treatment of Hematologic Malignancies, Beijing, China.
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Lizurej W, Mazurkiewicz Ł, Kowalski M, Szydłowska S, Wyrzykowski M, Lewandowski K. Superior sagittal sinus thrombosis in the course of mixed phenotype acute leukaemia treated with acute lymphoblastic leukaemia-like therapy-a case report. Thromb J 2023; 21:117. [PMID: 37974201 PMCID: PMC10652634 DOI: 10.1186/s12959-023-00561-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023] Open
Abstract
Mixed phenotype acute leukaemia (MPAL) is associated with worse overall survival, compared with other acute leukaemias in adults. Lack of clear treatment guidelines makes the therapy challenging. ALL-like induction and consolidation treatment followed by allo-HSCT is the preferred first-line treatment. We present a case of a 36-year-old woman diagnosed with MPAL (EGIL Myelo/B) with KMT2A rearrangement, treated with the PALG-ALL-7 (including PEG-asparaginase) protocol. On day 25 after the induction therapy initiation, numbness of limbs and dizziness were observed. Therefore, the imaging studies (CT and MRI) were performed and a diagnosis of thrombosis of superior sagittal sinus of the brain was established. Routinely performed blood coagulation tests showed prolonged APTT and PT, decreased antithrombin III activity and decreased free protein S concentration. LMWH treatment and substitutional therapy with antithrombin III were started, which resulted in a significant reduction in the thrombosis associated symptoms and improvement of the neurological status after 3 days. After induction and consolidation therapy, the patient obtained complete haematological remission and negative measurable residual disease. Six months after the diagnosis, allo-HSCT was successfully performed. During the 4 months follow-up, the patient remained MRD negative and thrombotic symptoms free. To the best of our knowledge, our communication has been the first report of such complication in an MPAL patient treated with PEG-asparaginase containing protocol in adults. We recommend increased vigilance in patients manifesting any mild neurological symptoms and early decision about the MRI study performance.
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Affiliation(s)
- Wojciech Lizurej
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Łukasz Mazurkiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Michał Kowalski
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Sylwia Szydłowska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Michał Wyrzykowski
- Department of Diagnostic Imaging, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Lewandowski
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland.
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Ravikumar V, Berkowitz J, Khan O, Garcia DP, Ratnasabapathy R. A Rare Case of Therapy-Related B-cell Acute Lymphoblastic Leukemia Arising From Acute Myeloid Leukemia. Cureus 2023; 15:e45745. [PMID: 37872919 PMCID: PMC10590473 DOI: 10.7759/cureus.45745] [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] [Accepted: 09/21/2023] [Indexed: 10/25/2023] Open
Abstract
Therapy-related acute lymphoblastic leukemia (t-ALL) is a rare potential complication of chemotherapy. We describe the case of a 47-year-old male patient who was originally diagnosed with t(8;21) positive acute myeloid leukemia (AML) in 2019, received chemotherapy, achieved remission, and was disease-free for the next two years. During a routine follow-up in 2022, he was found to have developed subclinical pancytopenia, and further studies indicated a diagnosis of pH-negative, near-tetraploid B-cell acute lymphoblastic leukemia (B-ALL) that was positive for a Tier 1 TP53 mutation, consistent with t-ALL. The patient had a prolonged treatment course complicated by social factors, such as the impact of both disease and treatment on his ability to work enough to make a living and live life with the quality he desired. The patient elected to pause treatment and resume it at a later date, after which, unfortunately, significant disease progression occurred and the patient died from complicating neutropenic sepsis and variceal bleeding. This case illustrates the challenges of managing social circumstances and patient goals in the setting of medically necessary but potentially harsh treatment courses. Given the aggressive nature of t-ALL and its overall poor prognosis, goals of care must be re-evaluated and discussed often to ensure alignment of therapy with a patient's wishes.
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Affiliation(s)
- Vishvaas Ravikumar
- Internal Medicine, Oregon Health & Science University (OHSU), Portland, USA
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Jacob Berkowitz
- Internal Medicine, Oregon Health & Science University (OHSU), Portland, USA
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Omar Khan
- Pathology, Aurora Diagnostics LMC Pathology Services, Las Vegas, USA
| | | | - Ramalingam Ratnasabapathy
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
- Hematology and Oncology, Comprehensive Cancer Centers of Nevada, Las Vegas, USA
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Abdo Y, Gibson GD, Jain SP, Milner CP, Hilal T. Treatment of Relapsed B/T-cell Mixed Phenotype Acute Leukemia With Blinatumomab. Cureus 2023; 15:e40661. [PMID: 37485162 PMCID: PMC10356569 DOI: 10.7759/cureus.40661] [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] [Accepted: 06/18/2023] [Indexed: 07/25/2023] Open
Abstract
Here, we describe the treatment of a patient with relapsed/refractory B/T mixed phenotype acute leukemia (MPAL) using blinatumomab monotherapy, the first bispecific T cell engager (BiTE) approved by the FDA for relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL). A 64-year-old man with a history of stage 3 chronic kidney disease and type 2 diabetes mellitus was discovered to have B/T MPAL on bone marrow biopsy during hospitalization for dyspnea due to pulmonary embolism. The patient achieved brief remission with blinatumomab treatment before succumbing to neutropenic sepsis. The lack of sufficient data to guide therapy in MPAL remains a challenge, highlighting the potential of new targeted approaches such as blinatumomab to improve outcomes in relapsed/refractory MPAL.
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Affiliation(s)
- Yasmeen Abdo
- School of Medicine, University of Mississippi Medical Center, Jackson, USA
| | - Geoffrey D Gibson
- Division of Hematology, University of Mississippi Medical Center, Jackson, USA
| | - Sarika P Jain
- Division of Pathology, University of Mississippi Medical Center, Jackson, USA
| | - Carter P Milner
- Division of Hematology, University of Mississippi Medical Center, Jackson, USA
| | - Talal Hilal
- Division of Hematology, University of Mississippi Medical Center, Jackson, USA
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, USA
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