急性单核细胞白血病M5a和M5b细胞遗传学与临床表现的比较

急性单核细胞白血病M5a和M5b细胞遗传学与临床表现的比较【摘要】　　为了比较急性单核细胞白血病M5a和M5b细胞遗传学差异，并研究其与临床行为之间的相互关系，采用骨髓直接法和24小时短期培养法制备染色体标本，用G显带技术对58例__初发急性单核白血病细胞进行核型分析，同时对其临床资料进行回顾性研究结果表明58例患者中正常核型28例，异常核型30例，其中正常核型在M5b中出现率高于M5a（P＝

0.0001），异常核型中11q23异常和＋8染色体在M5a中均较M5b常见（Plt;

0.01）；临床上异常核型的M5患者常有高白细胞（WBC）计数，中枢神经系统浸润，完全缓解CR率低及存活期明显缩短的特征结论急性单核细胞白血病在遗传和临床上是一组异质性疾病，但M5a和M5b似乎具有各自独特的遗传学背景和临床表现【关键词】急性单核细胞白血病；AML-M5a；AML-M5b；细胞遗传学　　ComparisonofCytogeneticsandClinical__nifestationsbetweenM5aandM5bofAcuteMonocyticLeukemia　　AbstractTocomparethecytogeneticdifferen__betweenM5aandM5bofacutemonocyticleukemiaandtostudythecorrelationbetweenkaryotypesandclinical__nifestations，atotalof58casesofdenovo_____AMLM5h__ebeeninvestigated.Chromosomemetaphasesofbone__rrow__llswerepreparedbyusingdirectmethodand24hoursshort-termculture.Thekaryotypeswere____yzedbyG-banding.Meanwhile，clinicalinfor__tionofthesecaseswerestu___dretrospectively.Theresultsshowedthattherewere28withnor__lkaryotypeand30withaberrantkaryotypein58cases.Thefrequencyofnor__lkaryotypeinpatientswithM5bwassignificantlyhigherthanthatinpatientswithM5aP=

0.

0001.The11q23aberrationsandtrisomy8weremorecommoninpatientswithM5aincomparisonwithpatientswithM5bPlt;

0.

01.ThepatientswithAMLM5withaberrantkaryotypehadahigherinciden__ofhyperleucocytosis，extramedullary__ntralnervesysteminfiltration，lowercompleteremissionCRrateandshorteroverallsurvival.Itisconcludedthatacutemonocyticleukemiaisaseriesofheterogeneousdiseases，adistinctivecytogeneticfeaturescanbeobservedbetweenpatientswithAMLM5aandM5b，theseresultswillprovideinsightsintotheclassificationandpathogenesismechani__ofAMLM5atmolecularlevel.　　Keywordsacutemonocyticleukemia;AML-M5a;AML-M5b;cytogeneticsAcutemyeloidleukemiaAMLcanbeclassifiedbyFABsystemintodifferentgroupsbasedon__llularmorphologyandcytochemistrystainingofbone__rrow__lls.Accordingtothedifferentiationstageofmonocytic__lls，acutemonocyticleukemiaAML-M5consistsoftwogroups:M5a，theper__ntageofmonoblastsis≥80%;M5b，the__jorityofmonocytic__llsarepromonocytes（blasts＜80%）［1］.Inaddition，he__tological__lignanciescanbeclassifiedaslymphocytic，myeloid，histocyticand__stocyticseriesbasedontheoriginof__lignant__llsbytheWHO.Eachgroupisdeterminedbymorphology，cytogeneticsandclinicalcharacteristics.However，thesetwoclassificationsystemscannotbeusedtodifferentiatethecytogeneticcharacteristicsandclinical__nifestationsbetweenpatientswithM5aandM5b.Inthepresentstudy，weinvestigated58newlydiagnosedAMLM5patientsinordertobettercharacterizethecytogeneticchangesandclinical__nifestationsofthesepatientsformoreaccurateclassificationandunderstandingofthepathogene-sisofthedisease，whichcouldleadtothedevelopmentofanoveltherapeuticstrategy.　　__terialsandMethods　　Patients　　DuringtheperiodfromJanuary2000toJune2004，58patientswerenewlydiagnosedwithAMLM5inthedepartmentofHe__tologyofUnionHospitalaffiliatedtoTongjiMedicalCollege，HuazhongUniversityofScien__andTechnologyWuhan.Theclinicalrecordsandlaboratorytestreportsofthesecaseswerereviewed.Theclinicaldiagnosiswas__debasedontheclinicalsymptoms，peripheralbloodcounts，bone__rrowexamination.26outofthe58patientswereclassifiedasM5aand32asM5b.Therewere12__lesand14fe__lesofAMLM5apatients，agedfrom18to59withamedianageof

39.5，while20__lesand12fe__lesofAMLM5bpatientsagedbetween28to66withamedianageof

48.　　Cytogenetic____ysis　　2-3mlsofheparinizedbone__rrowfrompatientswereculturedinRPMI1640supplementedwith20%fetalcalfserumand20U/mlheparin.The__lldensitywasadjustedto1×106/ml.Thesampleswereincubatedat37℃for24hours，thentreatedbycolchicineswiththefinalcon__ntrationof

0.05μg/mlforanother42minutes.Standardcytogeneticpreparationwas__de;amodifiedchromosomebandingtechniqueG-bandingwasused.Forchromosome____ysisatleast30-50metaphasechromosomesshouldbecountedineachsample，and10metaphasechromosomeswere____yzedbymicroscopyormicrophotography.Karyotypeswere____yzedaccordingtotheInternationalSystemforCytogeneticNomenclatureISCN.

1995.　　Protocols　　Allpatientsweretreatedwithregimensasfollows:1DAdaunorubicin45mg/m2perdaybyintr__enousinfusioniv，day1to3，pluscytarabine100-200mg/m2perdaybyintramuscularinjectionimday1to7;2HAhomoharringtonine2-3mg/m2byivperday，day1to3，pluscytarabine100-200mg/m2perdaybyim，day1to7;3IAidarubicin10mg/m2perdaybyiv，day1to3，pluscytarabine100-200mg/m2perdaybyimday1to7;4MEAmitoxantrone8-12mg/m2perday，day1to3，plusetoposide100mg/m2perdaybyivdrip，day4to5，pluscytarabine100-200mg/m2perdaybyim，day1to

5.Subsequently，somepatientsre__ivedstrengtheningchemotherapywithcytarabine

1.5g/m2twi__adayfor6days，whilepatientsolderthan70yearsre__ivedthesametherapyforonly3days.Outofthe58patients，twounderwenthu__nleukocyteantigen-__tchedallogeneicbone__rrowtransplantationandoneunderwentperipheralbloodstem__lltransplantationafterthediseaseswentintocompleteremission.　　Definitionofresponse　　Completeremissionwasdefinedineachprotocolasabsen__ofleukemiainthebone__rrowindicatedbylessthan5%blasts，recoveryofnor__lperipheralblood__llcountsasindicatedbyabsoluteneutrophilcount≥

1.5×109/L，andplateletcount≥100×109/L，andabsen__ofextramedullaryleukemia.　　Statistical____ysis　　ClinicalandcytogeneticcharacteristicsofAMLM5apatientswerecomparedwiththatofAMLM5bpatientsusingχ2test.　　Results　　Cytogenetic____ysis　　Outof58patients，

2848.3%hadnor__lkaryotypes，thefrequencyofwhichwassignificantlyhigherinthepatientswithAMLM5b

85.7%，n=24thanthatinthepatientswithAMLM5a

14.3%，n=4（Plt;

0.01）;

3051.7%hadaberrantkaryotypesbeinginvolvedin11q23/MLLAMLM5avsAMLM5b:833%vs

16.7%，Plt;

0.01，soletrisomy8AMLM5avsAMLM5b:

88.9%vs

11.1%，Plt;

0.01，trisomy8plus11q23/MLLAMLM5avsAMLM5b:333%vs

66.7%andotherchromosomeabnor__lities，outofwhichtrisomy21intwopatients，5q-inone，7q-inone，t9;22inone，andt8;16inanotherone.Theresultsofcytogenetic____ysisforallAMLM5patientsaresum__rizedinTable

1.　　Clinicalcharacteristics　　Outofallthepatients，abnor__llyhighwhiteblood__llcounts≥50×109/Lweredetectedin27patientsM5avsM5b∶14vs13;hepatosplenomegalywasobservedin22patientsM5avsM5b∶11vs11;extramedullarydiseaseintheskinwasfoundin16patientsM5avsM5b∶9vs7，enlargementoflymphnodesin20patients.15patientshad__ntralnervoussystemleukemiaM5avsM5b∶9vs6;14patientshadthedisseminatedintr__ascularcoagulationM5avsM5b∶8vs

6.Thecompleteremissionratewas

42.3%n=11forpatientswithM5a，

56.3%n=18forpatientswithM5b，and50%n=29forallAMLM5patients.Theper__ntageoftheone-yeardisease-freesurvival（DFS）inpatientswithAMLM5awas

26.9%n=7，whileitwas

34.4%n=11inpatientswithAMLM5b.TheclinicalcharacteristicsbetweenthetwosubtypeswerenotsignificantlydifferentP＞

0.

05.TheseresultsarelistedinTable

2.Table

1.CytogeneticdataforpatientswithAMLM5subtypes（略）Table

2.ClinicalcharacteristicsofAMLM5patientswithvariouskaryotypes（略）　　Discussion　　Specificnon-randomchromoso__labnor__litiesareoftenobservedin__rtainsubtypesofhe__tologic__lignancy.MoreaberrantcytogeneticshasbeendiscoveredinpatientswithAMLM5afterinitiallyfindingoft9；11p21；q23inM5apatientbyBerger［2］in

1980.Haferlachetal［3］consideredthat11q23aberrationandtrisomy8weresignificantlyassociatedwithAML-M

5.Tkachuketal［4］foundthat11q23abnor__litiesareinvolvedintheMLLgeneornamed“ALL1”or“HRX”，spanning90kbofcDNAandencodinga3968-aminoacidproteinwithmolecular__ssabout430kD.Thewild-typeMLLproteinhasthreeAT-hookDNAbindingdo__insandmultiplezincfingerdo__ins.MLLgene-encodedproductasatranscriptionfactorthen__ybindwiththegenesregulatingbodydevelopmentand__lldifferentiation［5］.ThegenerearrangementsofMLLsuchas11q23translocationalteritsstructureandfunctionand__yleadtoleukemogenesis.　　Meanwhile，thetrisomy8isachromosomeabnor__lity.Althoughtheinducingmechani__andthebiologicroleofthetrisomy8areunknown，therelationshipbetweenthetrisomy8andmonocytic__lignancyhasbeensuggested［6］.Theoccurren__oftrisomy8__yenhan__theexpressionofgenes，leadingtothedevelopmentofleukemias.Inthisstudy，theinciden__of“nor__lkaryotypes”washigherinpatientswithM5bthanthatinpatientswithM5aPlt;

0.001;theinvolvementof11q23aberrantionsandtrisomy8weredetectedmorefrequentlyinpatientswithM5athanthatwithM5bPlt;

0.01inaccordan__withpriorstu___s［3，6］.TheseresultsindicatethatthegenomicinstabilityismorecommonandcomplexinM5apatientleukemic__llsthanthatinM5b__lls.TheclinicalcharacteristicsofpatientswithAMLM5includedextramedullaryinfiltrationwithhighWBCcounts，lowcompleteremissionrateandshortdisease-freesurvivalDFS.Inourstudy，nosignificantdifferen__wasfoundregardingthosecharacteristicsbetweenthetwosubtypes，inagreementwiththeresultsfromthestudyoftheEasternCooperativeOncologyGroupECOGon81patientswithAMLM5［1］.　　Meantime，Schochetal［7］____yzed1__7AMLcaseswith11q23abnor__lities，andfoundthatthepatientswith11q23deletion/translocation/inversionwereoftenslightlyyoungerandhadhighWBCcounts，hepatosplenomegaly，__ntralnervoussysteminvolvement，lowcompleteremissionandshortDFS.TheclinicaldatafromtheSouthwestOncologyGroup［8］demonstratedthatthepatientswiththetrisomy8wereslightlyolder，andwithlowerWBCcounts，lowerper__ntagesofperipheralblasts，lowercompleteremissionandshorterDFSthanthoseofpatientswithoutthetrisomy

8.Becauseofthelimitedcasenumbers，thecomparisonofclinicaldataamongpatientswithvariousaberrantkaryotypeswasnotperformedinthisstudy，butlowercompleteremissionandshorterDFSwerestillevident.Inconclusion，theAMLM5patientsexaminedinthisstudyshowedasignificantheterogeneityincytogeneticsandclinical__nifestations.The11q23aberrantionsandtrisomy8weremorefrequentlydetectedinpatientswithAMLM5a，comparedwithpatientswithM5b.MostofthepatientswithAMLM5bhadanor__lkaryotype.ThepatientswithaberrantkaryotypeshadalowercompleteremissionrateandshorterDFS.TheseresultsprovidefurtherinsightsintothepathogenesisofAMLM5andmightleadtoabetterclassificationofthedisease.　　Acknowledgements　　TheauthorswouldliketothankProfessorDaohongZhouinMedicalUniversityofSouthCarolina，USA，forhelpfulEnglishpolishingonthe__nuscript.【____】　　1Tall__nMS，KimHT，PaiettaE，etal.AcutemonocyticleukemiaFrench-American-BritishclassificationM5doesnoth__eaworseprognosisthanothersubtypesofacutemyeloidleukemia:areportfromtheEasternCooperativeOncologyGroup.JClinOncol，2004；22:1276-1286　　2BergerR，BernheimA，WehHJ，etal.Cytogeneticsstu___sonacutemonocyticleukemia.LeukRes，1980；4:119-127　　3HaferlachT，SchochC，ShnittgerS，etal.DistinctgeneticpatternscanbeidentifiedinacutemonoblasticandacutemonocyticleukaemiaFABAMLM5aandM5b:astudyof124patients.BrJHae__tol，2002；118:426-431　　4TkachukDC，KohlerS，ClearlyML.InvolvementofahomologofDrosophilatrithoraxby11q23chromoso__ltranslocationsinacuteleukemias.__ll，1992；71:691-700　　5徐伟来，金洁，陈志妹等.8号染色体三体38例临床及实验研究.中华医学遗传学__，2003;20:528-531　　6Anonymous.Morphologic，immmunologic，andcytogeneticMICworkingclassificationoftheacutemyeloidleukemias.ReportoftheWorkshopheldinLeuven，Belgium，September15-17，

1986.Se-condMICCooperativeStudyGroup.Can__rGenetCytogenet，1988;30:1-15　　7SchochC，SchnittgerS，KlausM，etal.AMLwith11q23/MLLabnor__litiesasdefinedbytheWHOclassification:inciden__，partnerchromosomes，FABsubtype，agedistribution，andprognosticimpactinanunselectedseriesof1__7cytogenetically____yzedAMLcases.Blood，2003;102:2395-2402　　8Wol__nSR，GundackerH，AppelbaumFR，etal.Impactoftrisomy8+8onclinicalpresentation，treatmentresponse，andsurvi-valinacutemyeloidleukemia:aSouthwestOncologyGroupstudy.Blood，2002;100:29-

35.。