Leukemia (2010) 24, 740–747 & 2010 Macmillan Publishers Limited All rights reserved 0887-6924/10 $32.00 www.nature.com/leu
ORIGINAL ARTICLE Trisomy 11 in myelodysplastic syndromes defines a unique group of disease with aggressive clinicopathologic features SA Wang1, K Jabbar1, G Lu1, SS Chen1, N Galili2, F Vega1, D Jones1, A Raza2, H Kantarjian3, G Garcia-Manero3, TJ McDonnell1 and LJ Medeiros1 1
Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2Department of Internal Medicine, St Vincent’s Comprehensive Cancer Center, New York, NY, USA and 3Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Trisomy 11 in myelodysplastic syndromes (MDS) is rare, with undefined clinical significance and is currently assigned to the International Prognostic Scoring System (IPSS) intermediaterisk group. Over a 15-year period, we identified 17 MDS patients with trisomy 11 either as a sole abnormality (n ¼ 10) or associated with one or two additional alterations (n ¼ 7), comprising 0.3% of all MDS cases reviewed. Of 16 patients with Bone Marrow material available for review, 14 (88%) patients presented with excess blasts, 69% patients evolved to acute myeloid leukemia (AML) in a 5-month median interval and the median survival was 14 months. For comparison, we studied 19 AML patients with trisomy 11 in a noncomplex karyotype, of which, a substantial subset of patients had morphologic dysplasia, and/or preexisting cytopenia(s)/MDS. Genomic DNA PCR showed MLL partial tandem duplication in 5 of 10 MDS and 7 of 11 AML patients. A review of literature identified 17 additional cases of MDS with trisomy 11, showing similar clinicopathologic features to our patients. Compared with our historical data comprising 1165 MDS patients, MDS patients with trisomy 11 had a significantly inferior survival to patients in the IPSS intermediate-risk cytogenetic group (P ¼ 0.0002), but comparable to the poor-risk group (P ¼ 0.97). We conclude that trisomy 11 in MDS correlates with clinical aggressiveness, may suggest an early/evolving AML with myelodysplasia-related changes and is best considered a high-risk cytogenetic abnormality in MDS prognostication. Leukemia (2010) 24, 740–747; doi:10.1038/leu.2009.289; published online 14 January 2010 Keywords: myelodysplastic syndrome; trisomy 11; acute myeloid leukemia; overall survival; MLL partial tandem duplication
Introduction Trisomy 11 as a sole abnormality is an infrequent nonrandom chromosomal aberration observed in acute myeloid leukemia (AML). AML with trisomy 11 has been shown to be associated with a stem/progenitor cell immunophenotype with myeloid antigen expression, is not confined to a specific French– American–British (FAB) subtype and has been characterized by poor response to standard chemotherapy and unfavorable prognosis.1,2 Although no translocation involving 11q23 is identified by conventional karyotyping in de novo AML with trisomy 11, molecular analysis has shown that the MLL gene (also called ALL-1, HRX or Htrx) is frequently rearranged through partial tandem duplication (PTD).3–6 The duplicated region of the MLL gene consists of an in-frame repetition of Correspondence: Dr SA Wang, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA. E-mail:
[email protected] Received 9 November 2009; accepted 23 November 2009; published online 14 January 2010
exons in a 50 –30 direction spanning mainly exons 2–6 or 2–8. Although variable, each of the distinct fusion transcripts resulting from MLL PTD has been in frame and encodes the N-terminal region of MLL leading to a potentially translatable sequence. Myelodysplastic syndromes (MDS) or myelodysplastic/myeloproliferative neoplasms (MDS/MPN) with trisomy 11 as a sole abnormality or as part of a noncomplex karyotype are rare, and only sporadic cases have been reported in the literature.6–12 The clinicopathologic aspects of this neoplasm are not well defined, largely because of the rarity of this abnormality compared with other well-characterized cytogenetic alterations in MDS and MDS/MPN. According to the 1997 International Prognostic Scoring System (IPSS),13 trisomy 11 is grouped together with other miscellaneous single chromosomal aberrations within the intermediate-risk cytogenetic group. In a previous study consisting of 1029 primary (de novo) MDS patients,14 we identified four patients with MDS associated with trisomy 11 as a sole abnormality. These patients appeared to have an aggressive clinical course, compared with MDS patients with other cytogenetic abnormalities considered as intermediate risk. We suspected that trisomy 11, which has been shown to be associated with high frequency of MLL PTD in AML patients, might carry the same molecular alteration in MDS. If true, the presence of trisomy 11 in MDS would be best considered as a poor- rather than intermediate-risk cytogenetic. To test this hypothesis, we retrospectively analyzed 17 patients with MDS (n ¼ 16) or MDS/MPN (n ¼ 1) with trisomy 11 as a sole cytogenetic abnormality or as a part of a noncomplex karyotype, and compared these cases to 19 patients with AML associated with trisomy 11. We studied the clinicopathologic characteristics of these patients, and assessed for MLL PTD in cases with available DNA using PCR analysis, results were confirmed by Southern blot analysis in a subset of cases. A review of 17 cases reported in the literature, mostly in the form of case reports, is also provided.
Materials and methods
Patients The files of the Department of Hematopathology at the University of Texas MD Anderson Cancer Center (MDACC), University of Massachusetts Memorial Medical Center and St Vincent’s Comprehensive Cancer Center from 1995 to the beginning of the study were searched for patients with MDS or MDS/MPN with trisomy 11 as a sole abnormality or as part of a noncomplex karyotype. For comparison, 19 patients with AML associated with trisomy 11 were selected from MDACC in the
Trisomy 11 in MDS SA Wang et al
741 same time period. Clinical information was obtained by review of the electronic medical records for any history of antecedent chemotherapy, radiation therapy, hematologic neoplasm, cytopenia(s), treatment information and outcomes. This study was approved by the institutional review boards of all the participating institutions. MDS and MDS/MPN cases were reclassified according to 2008 World Health Organization (WHO) classification criteria15 after pathology review and incorporation of molecular genetic information. Overall survival (OS) was measured from the day of diagnosis of MDS, MDS/ MPN or AML until death from any cause, censored for patients known to alive till the last follow-up. The survival of patients with MDS associated with trisomy 11 was compared to that in our historical database consisting of 1165 MDS patients treated by the same group of hematologists between 1995 and 2006.
Morphologic evaluation All patients had representative bone marrow (BM) aspirate smears and trephine biopsy specimens available for evaluation. A 500-cell BM differential count was performed based on examination of multiple fields of the aspirate smears. For the diagnosis of morphologic dysplasia in BM, features of dyserythropoiesis, dysgranulopoiesis and dysmegakaryopoiesis had to be present in X10% of cells of the respective lineage, as specified in the 2008 WHO classification.15 In AML cases, aspirate smears were specifically assessed for Auer rods, granulocytic differentiation and morphologic evidence of dysplasia in maturing elements. To allow for comparison with cases reported previously in the literature, we also classified cases using the FAB classification criteria.
respectively, whereas HindIII digests were hybridized to the B859 probe, stripped and then hybridized to the SAS1 probe. Southern blotting, stripping, probe radiolabeling and autoradiography were performed using standard techniques.
FLT3 and K- and N-RAS mutation analyses A fluorescence-based multiplex PCR assay was used to detect internal tandem duplication (ITD) and D835 point mutations of the FLT3 gene using DNA isolated from BM aspirate or peripheral blood samples, as previously described.18 K-RAS and N-RAS mutations were tested using PCR followed by pyrosequencing as described previously.19
Literature review All published cases in the English literature with a confirmed diagnosis of MDS or MDS/MPN associated with trisomy 11 were reviewed in PubMed. The clinicopathologic characteristics, including patient demographic information, BM findings, frequency and interval of AML transformation, and OS were summarized and analyzed.
Statistical analysis Mann–Whitney test was used for numerical comparison between two groups. Fisher’s exact test and w2-test were applied for categorical variables. Patient survival was estimated by the Kaplan–Meier method from the date of BM diagnosis until death from any cause or until the last patient follow-up. Survival curves were statistically compared by the log-rank test. Differences between the two groups were considered statistically significant if P-values were o0.05 in a two-tailed test.
Cytogenetic analysis Conventional cytogenetic analysis was performed in three laboratories using standard methods with minor differences in technique. In all cases, G-banded metaphase cells were prepared from unstimulated BM aspirate cultures using standard techniques. Twenty metaphases were analyzed in all cases, if available, and the results reported using the International System for Human Cytogenetic Nomenclature. In some cases a lesser number of metaphases were available, but in all cases the numbers of metaphases were adequate to issue a karyotype.
Molecular studies DNA preparation and standard PCR in detection of MLL partial tandem duplications. Mononuclear cells obtained from BM aspirate specimens were isolated by Ficoll–Hypaque gradient centrifugation and genomic DNA was extracted using a standard isolation procedure.16 PCR was performed according to the methods described by Caligiuri et al.3 using the primer sets 6.1 (50 -GTCCAGAGCAGAGCAAACAG-30 ) from exon 6 (sense orientation) and 2.0R (50 -CGCACTCTGACTTCTTCATC-30 ) from exon 2 (antisense orientation). In brief, PCR was performed on genomic DNA using Taq Extender PCR additive (Stratagene, La Jolla, CA, USA) according to the manufacturer’s instructions. The reactions were for 35 cycles (95 1C for 1 min, 60 1C for 1 min and 72 1C for 3.5 min), followed by a 10 min extension at 72 1C.
Southern blot analysis. Approximately 6 mg of genomic DNA was digested to completion with BamHI. HindIII or EcoRI restriction enzymes. Probes for Southern blot hybridization, designated B859 and SAS1,17 were used. The BamHI and EcoRI digests were hybridized with the B859 and SAS 1 probes,
Results
Clinical characteristics of patients with myelodysplastic syndromes or myelodysplastic/myeloproliferative neoplasms associated with trisomy 11 A total of 42 patients with a confirmed diagnosis of MDS or MDS/MPN with trisomy 11 were identified from our database consisting of approximately 5000 MDS and MDS/MPN cases. In 25 of these cases, trisomy 11 was present as a part of a very complex karyotype (median abnormalities ¼ 10; range, 5–27). Among this subgroup, 14 (56%) patients acquired the complex karyotypes including trisomy 11 at the time of either transformation of AML or relapse of AML; 6 (24%) patients were considered to have therapy-related MDS (t-MDS) and 5 (20%) patients presented with refractory anemia with excess blasts (RAEB). Owing to the complexity of these karyotypic abnormalities in which the significance of trisomy 11 is obscured, these cases were excluded from the final analysis. As a result, the study group included 17 patients with MDS (n ¼ 16) or MDS/ MPN (n ¼ 1) who had trisomy 11 either as a sole abnormality, or associated with one or two other abnormalities (Table 1). The overall frequency is approximately 0.3% of all MDS patients. Patient 3 in the study group had a history of chronic lymphocytic leukemia treated with chemotherapy (t-MDS). The remaining 16 patients had no history of malignancies and were considered as primary (de novo) MDS or MDS/MPN. The 17 patients in the study group included 13 men and 4 women with a median age of 75 years (range, 47–85). The median hemoglobin was 9.4 g per 100 ml (range, 6.0–11.8), median absolute neutrophil count 1.0 109 per liter (range, 0.3–10.5) and median platelet count 105 109 per liter (range, 3–269). Leukemia
Leukemia
47/M
90/11
85/17
81/M
12
13
50/15
82/M
11
70/13
85/M
10
Cytopenia for 1 year, with +8, no dysplasia,
50/6
75/M
9
(RARS for 10 months, normal karyotype)
50/3
81/M
8
90/9
76/M
7
35/6
50/F
6
20/8
74/M
5
Low-grade MDS, for 19 months, without +11
85/8
62/M
90/0
70/F
CLL, treated with chemotherapy
3
4
75/14
76/F
Crohn’s disease
70/16
BM cellularity%/ blast%
2
Age (years)/ sex
79/F
Other relevant medical history
Erythroid Myeloid Megas
Erythroid Myeloid Megas
Erythroid
Myeloid
Erythroid Mega
Myeloid Erythroid Mega Erythroid Myeloid
Myeloid Erythroid
Myeloid, Erythroid Mega
Myeloid, Erythroid Mega
Erythroid Mega
Myeloid, Erythroid Mega Myeloid, Erythroid Mega
BM dysplasia
49,XY,+8,+10,+11[18]/46, XY[2]
47,XY,+11[4]/46,XY[16]
47,XY,+8, del(16)(q11.2) [9]/48,idem+11[7]/ 46,XY[4]
RAEB-2
RAEB-2
48XY+8+11[44]/46,XY[2]
47, XY, +11[5]/46,XY[25]
CMML-2
RAEB-2
RAEB-1
47,XY,+11[2]/46,XY [20]
47,XY,+11[9]/46,XY[11]
RAEB-1
RCMD
47,xy,+11[8]/ 48,xx,+2,+11[1]/46, xx[10]
47,xy,+11[15]/46,xy[5]
RAEB-1
RAEB-1
47,XY,+11[5]/46,XY[15]
RAEB-1
47,XX,+11[8]/46,XX[12]
RAEB-2
47,XY,+11[19]/46,XY[1]
47,XX,+11[18]/46,XX[2]
RAEB-2
t-MDS
Cytogenetics
2008 WHO classification
AML, 1m (FAB-RAEB-t, 29% blasts)
AML, 35m (FAB-RAEB-t, 27% blasts)
No further BM biopsy performed
RAEB-2, 6m, with 47,XY,+11[17]/46, XY[3] AML, 8m, with 47,XY,+11[20] Lost follow-up
RAEB-2, 10m
AML, 5m (FAB-M2, 53% blasts)
AML, 3m (FAB-M2, 33% blasts),
AML, 5m (FAB-M2, 30% blasts) 47,XY,+11[20]
RAEB-2, followed by AML, 9m (FAB-M4, 57% blasts)
AML, 3m (FAB: RAEB-t, 28% blasts)
AML, 13m No details of the AML subtype.
Disease progression and interval (months)
The clinicopathological, molecular genetic features of patients with MDS; MDS/MPN with trisomy 11
1
No (MR/ name)
Table 1
Decitabine for MDS, followed by BMT. Alive, 60 months
Low-dose chemotherapy for MDS, died, 9 months Chemotherapy for CMML-2; salvage chemotherapy for AML, died, 58 months No chemotherapy, investigating agents, died, 8 months
MDS treatment unknown. Induction chemotherapy for AML, died, 31 months MDS treatment unknown. Induction chemotherapy for AML, died, 48 months Supportive care for MDS, Induction chemotherapy for AML, died, 8 months Vadaza and thalidomide, died, 13 months Investigating agents for MDS. Induction chemotherapy for AML, died, 14 months Investigating agents for MDS, died, 15 months
5-Azacitidine for RAEB-2; clofarabine for AML, Died, 9 months No treatment for MDS; clofarabine for AML, died, 10 months
5-Azacitidine, died, 19 months
Treatment, outcome, survivala
RAS Negative JAK2 Negative FLT3-D835 Mutation Positive at AML phase Not performed
No t(8;21) No inv(16)
Not performed
FLT3 Negative
FLT3 Negative
Positive (at the time of AML)
Not performed
Not performed
Negative
Negative
Not performed
Not performed
FLT3 ITD positive at the AML phase
RAS Negative FLT3 Negative at MDS and AML phases
Not performed
Not performed
Positive (at time of AML)
Positive
Negative
FLT3 Negative
KIT Negative FLT3 Negative
Positive
Not performed
ND
Additional molecular studiesb
Not performed
MLL PTD by PCR
Trisomy 11 in MDS SA Wang et al
742
Trisomy 11 in MDS SA Wang et al
17
Abbreviations: AML, acute myeloid leukemia; BM, bone marrow; BMT, bone marrow transplantation; CLL, chronic lymphocytic leukemia; CMML, chronic myelomonocytic leukemia; F, female; FAB, French–American–British; ITD, internal tandem duplication; M, male; MDS, myelodysplastic syndromes; ND, not done; PTD, partial tandem duplication; RAEB, refractory anemia with excess blasts; RARS, refractory anemia with ring sideroblasts; RCMD, refractory anemia with multilineage dysplasia. a Survival was calculated from the time of MDS diagnosis with trisomy 11 abnormality to the last follow-up. b Most of the tests were performed at the admission as part of the clinical work-up, only FLT3 including ITD and D835 point mutation were specifically performed on all samples with available genomic DNA.
FLT3 Negative Negative AML, 2m (FAB-RAEB-t, 25% blasts) 47,XY,+11[20] not available 70/M
Erythroid Myeloid Megas
Material not available for review
RAS Negative t(8;21) Neg Negative
Induction chemotherapy, BMT, died of transplantassociated mortality, 30 months Investigating agents, alive, 12 months AML, 1m (FAB-M2, 41% blasts), 48,XY,+8, +11[9]/ 46,XY[11] 48,XY,+8, +11 [5]/ 46,XY[15] 15
16
14
RCMD 9 months, +8
68/M
45/7 (7% blasts in blood) 30/17 77/M
Erythroid Myeloid
RAEB-2
Not performed Continuously increased blasts (19%) 47,XY,+8[5]/47,XY,+11[4]/ 46,XY [11] RAEB-2
Treatment unknown, died, 5 months
RAS Negative FLT3 Negative at MDS and AML phases RAS Negative t(8;21) Negative Positive Treatment unknown, died, 1 month 25/10 73/M
Erythroid Myeloid Megas Myeloid Megas
No further BM biopsy performed 49,XY,+11,+19,+22[16]/ 46,XY[3] RAEB-2
MLL PTD by PCR BM cellularity%/ blast% Age (years)/ sex Other relevant medical history No (MR/ name)
Table 1 (Continued )
BM dysplasia
Disease progression and interval (months) Cytogenetics 2008 WHO classification
Treatment, outcome, survivala
Additional molecular studiesb
743 After diagnosis of MDS or MDS/MPN, patients received various treatments (Table 1), including supportive care, investigational agents, thalidomide and derivatives, 5-azacitidine (Vidaza) and 5-aza-20 -deoxycytidine (Decitabine). Complete clinical follow-up was available in 16 patients. With a median follow-up interval of 13.5 months (range, 1–60 months, including alive and dead), 11 (69%) patients developed AML in a median interval of 5 months (range, 1–36 months). Of the remaining five patients whose MDS did not transform to AML, patients either died too soon (patients 10 and 14) or showed further increased blasts as evidence of disease progression (patients 7 and 15) or received BM transplant soon after the diagnosis of MDS (patient 13). The median OS of all patients was 14 months.
Morphologic assessment and disease classification The study group patients received the following diagnoses: one t-MDS, one refractory cytopenia with multilineage dysplasia (RCMD), one chronic myelomonocytic leukemia-2 (CMML-2); five RAEB-1 and eight RAEB-2. Patient 17 had a diagnosis of ‘MDS’ associated with trisomy 11 before referral, but the BM slides and karyotype were not available for review. Four patients (cases 5, 9, 12 and 16; Table 1) had a diagnosis of low-grade MDS (blastso5%) without trisomy 11, but progressed to RAEB at the time trisomy 11 detected. BM specimens showed a median cellularity of 60% (range, 20–95%) and a median blast count of 9.5% (range, 0–17%). Morphologic dysplasia was invariably present, involving one lineage in two patients; bilineage in six patients and trilineages in eight patients. None of BM specimens showed substantial fibrosis, increased eosinophils/basophils or Auer rods. Twelve cases had peripheral blood smears available for review, six revealed circulating blasts ranging from 1 to 7%. For the 11 cases that transformed to AML, all were classified as AML with myelodysplasia-related changes (AML-MRC), arising from preexisting MDS, using 2008 WHO classification criteria. According to FAB classification criteria, four were RAEB in transformation (RAEB-t), two were M1, four M2 and one M4 (Table 1).
Cytogenetics Trisomy 11 appeared as a sole chromosomal abnormality in 10 patients, and was associated with one or two additional abnormalities in seven patients. Among the additional chromosomal abnormalities, trisomy 8 was most frequent (five cases), followed by other trisomies involving chromosomes 10, 2, 22 and 19. Patient 13 showed del(16)(q11.2). No patients had balanced or unbalanced translocations. Trisomy 11 was present at the time of diagnosis in 13 patients, and acquired at the time low-grade MDS progressed to RAEB in 4 patients (cases 5, 9, 12 and 15). In all 11 patients who underwent AML transformation, trisomy 11 was present in the AML phase and in a higher proportion of metaphases. No additional chromosomal abnormalities were detected by conventional karyotype at the time of transformation to AML.
Acute myeloid leukemia with trisomy 11 abnormality A total of 19 patients who had AML with trisomy 11 in a noncomplex karyotype were retrieved from MDACC data files for comparison, and the clinical features are summarized in Supplementary Table 1. These included 12 men and 7 women, with a median age of 69 years (range, 33–89). Notably, two Leukemia
Trisomy 11 in MDS SA Wang et al
Leukemia
Overall survival (months), median (range)
Other mutations
Abbreviations: AML, acute myeloid leukemia; MDS, myelodysplastic syndromes; MDS/MPN, myelodysplastic/myeloproliferative neoplasm; NA, detailed information not available; PTD, partial tandem duplication.
0.45 (1 and 2) 0.96 (1 and 3) 11.5 (2–71)
FLT-3 (3/12, 25%); RAS: 0/12 9 (1–96)
69 (33–89) 12/7 80 (10–95) 61 (19–93) NA NA 7/11
69 (52–86) 7/5 NA NA 12/16 (75%) 7 (2–18) 0/4 at MDS 1 at AML transformation NA
75 (47–85) 13/4 60 (20–95) 9.5 (0–17) 11/16 (69) 5 (1–36) 3/8 (at MDS) 2 at AML transformation FLT-3 (2/10, 20%, at AML transformation) RAS: 0/5 14.0 (1–60)
In total, we identified 17 patients who had MDS or MDS/MPN associated with trisomy 11 reported in the English literature with basic information available. These cases were reported by authors from 12 institutions. Disease classification was based mainly on the FAB criteria, with more recent cases classified according to the 2001 WHO classification criteria. Based on published data describing morphologic dysplasia and blast number, these cases could be reclassified according to the 2008 WHO criteria as follows: 2 t-MDS; 2 CMML-1; 1 CMML-2; 1 RCMD and 11 RAEB. The demographic and cytogenetic features of these patients are shown in Supplementary Table 2. Of 17, 14 (82%) cases showed increased blasts in BM at presentation; and of 16, 12 (75%) patients with available follow-up transformed to AML with a median interval of 7 months (Supplementary Table 2). MLL PTD was performed in five cases (in Supplementary Table 2, cases 9, 10 and 15–17), and was positive in one case that was collected in AML phase. The OS was 11.5 months (range, 2–71).
Age (years), median (range) Sex (male/female) Bone marrow cellularity (%), median (range) Bone marrow blasts (%), median (range) AML transformation, number (% of patients) AML transformation interval (months) MLL PTD
Literature review
Table 2
Genomic DNA from fresh frozen BM aspirate samples was available for MLL PTD for PCR analysis in 10 MDS patients (of which 4 samples were collected at the AML phase) and 11 AML patients. All DNA samples were assessed for MLL PTD at least twice, and a positive result was confirmed in replicates (Figure 1). Five of the ten MDS patients (50%) were found to have MLL PTD (Table 1; Figure 1); it is noteworthy that in two patients (cases 3 and 12) samples were also collected at the time of AML evolution and the results were confirmed in samples obtained at two time points in both patients. In the AML patients, MLL PTD was detected in 7 of 11 patients; 2 of these cases were confirmed using Southern blot analysis. FLT3 ITD but not D835 mutations were detected in 3 of 12 (25%) in AML patients. FLT3 was tested in 10 MDS patients, showing D835 point mutation in patient 3 and FLT3 ITD in patient 12 at the time of AML transformation, but not in any patients in the MDS phase. KRAS and NRAS were negative in all 5 MDS and 12 AML cases tested (Table 2).
Comparisons of MDS and AML with trisomy 11 abnormality
Molecular studies
(1) MDS or MDS/MPN (n ¼ 17)
(2) MDS or MDS/MPN in literature (n ¼ 17)
(3) AML (n ¼ 19)
P
patients had preexisting MDS; and five patients presented with cytopenia(s) of various duration. Morphologic evidence of dysplasia was observed in one or more lineages of variable severity in 12 of 14 cases that had sufficient nonblast elements available for evaluation. According to the 2008 WHO classification, these AML cases were classified as follows: one therapy-related AML (1); six AML-MRC; five AML, not otherwise categorized (NOS) without maturation; two AML NOS with maturation, one AML NOS myelomonocytic; two AML NOS monoblastic; one AML NOS acute erythroid leukemia; and one AML NOS megakaryoblastic leukemia. According to FAB classification these cases were classified as RAEB-t (n ¼ 5); M0 (n ¼ 1); M1 (n ¼ 6); M2 (n ¼ 2); M4 (n ¼ 1); M5a (n ¼ 2); M6a (n ¼ 1); and M7 (n ¼ 1). Treatment information was available for all patients. Fifteen patients received induction chemotherapy: seven were resistant, and eight achieved complete remission but seven experienced relapse shortly. Only one patient who received BM transplant achieved long-term survival. The median OS was 9 months (range, 1–96 months). The clinicopathologic features of the individual patients are listed in Supplementary Table 1, and the overall features were compared with MDS cases with trisomy 11 as shown in Table 2.
0.20 (1 and 2 combined versus 3) 0.76 (1 and 2 combined versus 3) 0.21 (1 and 3) o0.0001 (1 and 3) 1.00 (1 and 2) 0.48 (1 and 2) 0.49 (1 and 2) 0.34 (1 and 3) 0.24 (FLT3) (1 and 3)
744
Trisomy 11 in MDS SA Wang et al
745
Figure 1 Genomic DNA PCR of the MLL gene showing amplified bands in five myelodysplastic syndrome (MDS) patients (Panel a, patients 2, 3, 12, 13 and 14) and seven patients with acute myeloid leukemia (Panel b, patients 4, 5, 9, 10, 13, 16 and 19). M, marker; WT, normal bone marrow; W, water.
The comparisons between MDS, our series and the cases reported in literature, and AML with trisomy 11 abnormalities are shown in Table 2.
Survival comparison with our historical MDS data All 17 cases in our series and 14 cases reported in the literature review had survival information available (n ¼ 31), showing a median OS of 11.5 months (range, 2–71). These cases were compared with 1165 MDS patients, including 1024 patients with primary MDS, and 141 patients with t-MDS. Using IPSS criteria, we categorized cytogenetic results of these 1165 patients as ‘good risk’ in 739; ‘intermediate risk’ in 196 patients and ‘poor risk’ in 230 patients. The OS of MDS patients with trisomy 11 was significantly shorter than that of MDS patients with intermediate-risk cytogenetic abnormalities (14 versus 28 months) (Kaplan–Meier, log-rank P ¼ 0.0002), and comparable to MDS patients with poor-risk cytogenetic abnormalities (14 versus 10 months, P ¼ 0.97) (Figure 2).
Discussion We report the first series of patients with MDS or MDS/MPN associated with trisomy 11 as a sole abnormality or as part of a noncomplex karyotype. These patients were selected from three large medical centers over the past 15 years. All these cases showed aggressive features including increased blasts at presentation, a strikingly high frequency of transformation to AML within a short interval and a short OS. We showed that MDS with trisomy 11 shared many features with AML with trisomy 11, and harbored similar frequency of MLL PTD. The frequency and clinical significance of trisomy 11 as a sole abnormality or as part of a noncomplex karyotype in MDS had not been specified, even in the recently reported large-series studies with focus on the miscellaneous cytogenetic alterations in MDS.14,20,21 The results of our study showed an overall frequency of approximately 0.3% in MDS, and most cases were of primary MDS. The clinicopathologic features we observed indicate that trisomy 11 is important in leukemogenesis or disease progression. This is evident for a number of reasons. First, there was no association with del(7q) or -7, or other balanced translocations such as t(15;17), t(8;21), inv(16), inv(3), commonly seen in high-grade MDS or AML. Instead, associations with other trisomies, or other cytogenetic abnormalities commonly related to low-grade MDS, such as þ 8, del(5q), were relatively common, mostly present as cytogenetically related clones. Second, most cases presented with increased BM blasts in the range of RAEB, and in a strikingly short interval, transformed to AML. Third, there were no additional cytogenetic abnormalities required for AML evolution. Trisomy 11 was
Figure 2 Overall survival (OS) comparison of 31 patients (17 from our series, 14 from literature) with trisomy 11 and myelodysplastic syndromes (MDS) or myelodysplastic/myeloproliferative neoplasm (MDS/MPN) with our historical data comprising 1165 MDS MPN patients. The median OS of MDS and MPN patients was 14 months, significantly lower to MDS patients with good-risk cytogenetics (n ¼ 739, median OS 48 months, Po0.0001) and intermediate-risk cytogenetics (n ¼ 196, median OS 28 months, P ¼ 0.0002), but comparable to MDS patients with poor-risk cytogenetics (n ¼ 230, median OS 10 months, P ¼ 0.97).
persistent in the AML phase, and was found in a high number of metaphases by conventional karyotyping. Lastly, four cases in our series had low-grade MDS with no trisomy 11 abnormality and trisomy 11 was detected at time of progression to RAEB. We have searched the English literature for similar patients who had MDS associated with trisomy 11 as a sole abnormality or as part of a noncomplex karyotype, and we identified 17 patients reported from 12 institutions. These cases showed strikingly similar aggressive clinicopathologic features to that observed in our series as increased BM blasts at the time of presentation, a high frequency of subsequently developing AML and a short survival. We also compared these patients with our historical MDS database of 1165 MDS patients. Trisomy 11 in MDS predicts a clearly shorter OS than that of patients with other cytogenetic alterations in the intermediate-risk cytogenetic category, and more akin to patients with poor-risk cytogenetics. We also compared these MDS patients with their AML counterparts. Similar to those reported by others,1,2,6 AML with trisomy 11 in our series showed frequent morphologic dysplasia, frequent preexisting MDS/cytopenias and low blast number in the range of 20–30%, features overlapping with MDS associated with trisomy 11. In addition, we showed that patients with AML and trisomy 11 were either resistant to conventional induction chemotherapy or experienced rapid disease relapse, and had a very short OS. These observations led us to question whether the MDS associated with trisomy 11 represents true MDS or is Leukemia
Trisomy 11 in MDS SA Wang et al
746 better classified as early/evolving AML-MRC; and if the neoplasm harbors certain molecular alterations that could explain their clinical aggressiveness. AML with trisomy 11 has been shown to have a high frequency of MLL PTD22–24 and interestingly, this MLL PTD likely occurs in the extra copy of chromosome 11.25 Although the hypothesis that MLL PTD is leukemogenic has been challenged by its ubiquitous existence in healthy individuals and their life-long persistence,26 recent observations and animal models have shown that MLL PTD disturbs normal hematopoiesis in a gain-of-function manner, as well as DNA hypermethylation and epigenetic silencing of the tumor suppressor gene.27,28 Particular mutations have been shown to correlate with the emergence of secondary aneuploidy, such as trisomy 8 with RAS mutation,29 trisomy 4 with KIT mutation.30 The selection of different chromosomes might be related to the dosage effects of a particular gene, or the entire set of genes on these chromosomes on myeloid cells from particular stages of differentiation, as well as alterations in transcript levels of mitotic spindle kinases. In our study group we detected MLL PTD within exons 2–6 region in half of MDS cases, although in two of the cases the samples were collected in AML phase. Rege-Cambrin et al.6 detected MLL PTD in 7 of 13 (54%) cases of AML with trisomy 11, but not in 3 MDS cases using reverse transcription–PCR and Southern blot analyses. Yamamoto et al.12 detected MLL PTD in a case of AML derived from MDS. In a recent study reported, MLL PTD was found in 8 of 163 (5%) of RAEB cases, and 2 of 210 (1%) low-grade MDS cases; however, the karyotype information of these cases was not revealed.31 It is important to recognize that MLL PTDs are highly variable and that Southern blot analysis with the currently available probes may not detect all PTDs. This is also true for the currently used nested reverse transcription–PCR using two primer sets.17 Conversely, blast numbers are low in MDS cases, and the molecular assays may not be adequately sensitive for detection when comparing MDS with AML cases with a high blast count. Nevertheless, the results of our study showed that MDS with trisomy 11 in a noncomplex karyotype carries a frequency of MLL PTD similar to that of AML with trisomy 11, although the signals were weaker, likely due to lower blast counts in MDS specimens. In addition, FLT3 ITD was detected in 25% of AML cases, and in another case of MDS at time of AML phase, but not in MDS cases, indicating that additional proliferation signals may contribute to higher number of blasts in AML or at time of AML transformation. In summary, our study data show that trisomy 11 in MDS and MDS/MPN should not be placed in the intermediate-risk cytogenetic group as is currently assigned by the IPSS. Instead, trisomy 11 represents a high-risk karyotypic abnormality denoting an aggressive clinical course. Cases of MDS with trisomy 11 share some features with their AML counterparts and carry MLL PTD in a substantial subset of cases. These observations suggest that cases of MDS with trisomy 11 may represent an early/evolving AML-MRC, analogous to AML with recurrent cytogenetic abnormalities, in which some patients may present with lower blasts at initial presentation but otherwise have a typical AML clinical course, and should be treated more aggressively.
Conflict of interest The authors declare no conflict of interest. Leukemia
Acknowledgements We thank Dr Hwei-Fang Tien and her assistant Shau-Chi at the National Taiwan University Hospital, Taipei, Taiwan for the technical support in MLL PTD study using genomic DNA PCR.
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