Clinical Cancer Investigation Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 8  |  Issue : 3  |  Page : 79--83

11q23 translocation in children with acute lymphocytic leukemia following primary response to chemotherapy: prognostic significance and diagnostic accuracy


Arash Alghasi, Kaveh Jaseb, Mohammad Pedram, Bijan Keikhaei, Hadi Rezaeeyan, Hamid Galehdari, Ali Mohammad Malekaskar, Fakher Rahim, Marziyeh Abbasi Nasab 
 Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Correspondence Address:
Arash Alghasi
Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
Iran

Abstract

Background: Cytogenetic abnormalities in leukemia cells have strong prognostic values for different clinical subgroups, clinical features, and therapeutic outcomes. Patients and Methods: This study was conducted on 100 children with acute lymphocytic leukemia referred to Ahvaz Shafa Hospital during 2012–2017. The patients were diagnosed by a specialist through examination of morphology and flow cytometry, testing bone marrow specimen on the 7th day of treatment, and a karyotype and cytogenetic test are performed. Results: There was no relationship between the t(11q23) and gender nor age of children. Besides, the mean white blood cell (WBC) counts in patients who were negative for 11q23 and those positive revealed a statistically significant relationship between WBC count and 11q23 (P = 0.022). Conclusion: A significant association between the 11q23 translocation and primary response to chemotherapy is existed. Diagnostic accuracy of these tests for detecting t(11q23) is generally high, as well as sensitivity and specificity are optimal for all anomalies.



How to cite this article:
Alghasi A, Jaseb K, Pedram M, Keikhaei B, Rezaeeyan H, Galehdari H, Malekaskar AM, Rahim F, Nasab MA. 11q23 translocation in children with acute lymphocytic leukemia following primary response to chemotherapy: prognostic significance and diagnostic accuracy.Clin Cancer Investig J 2019;8:79-83


How to cite this URL:
Alghasi A, Jaseb K, Pedram M, Keikhaei B, Rezaeeyan H, Galehdari H, Malekaskar AM, Rahim F, Nasab MA. 11q23 translocation in children with acute lymphocytic leukemia following primary response to chemotherapy: prognostic significance and diagnostic accuracy. Clin Cancer Investig J [serial online] 2019 [cited 2019 Oct 20 ];8:79-83
Available from: http://www.ccij-online.org/text.asp?2019/8/3/79/263407


Full Text



 Introduction



Acute lymphocytic leukemia (ALL) is one of the most common types of childhood cancer that affects different types of lymphocytes (B-cells or T-cells) that make up lymphoid tissues and develops and gets worse quickly.[1] ALL accounts for approximately 75% of childhood leukemia.[2] ALL is divided into subtypes based on the type of involved lymphocytes and the B-cell subtype counts for 80%–85% of all ALL types, compared with the 15% share of the T-cell subtype of children and adults.[3] The etiologies of the disease are not fully known, but the current evidence a multifactorial etiology for ALL including genetic and environmental factors.[4] A number of clinical and laboratory parameters have prognostic value in ALL children, which can play significant role in designing treatment and management of the disease.[5] These factors include the age of patient at the time of diagnosis, white blood cell (WBC) count, gender, platelet count, hemoglobin level, serum immunoglobulin level, race, response to treatment, blast cell morphology, and a number of chromosomal abnormalities, especially translocations.[6]

Chromosomal translocations or displacements are abnormalities, caused mainly by chromosomal defects and are one of the most important risk factors of cancers.[7] The most common translocation in ALL is t(12; 21), which is associated with a favorable prognosis that usually occurs in 1–10 years old children.[8],[9] Children younger than 5 years of age often exhibit chromosomal abnormalities of type t(4; 11) translocation, with a high risk of failed therapies. Philadelphia chromosome t(9; 22) accounts for about 5% of entire ALL patient but does not have high prognostic value for the disease.[10] Chromosome 11 translocations are the most common chromosomal abnormalities in ALL.[11] These translocations are present in approximately 15% of ALL cases, 5% of acute myeloid leukemia (AML) cases, and 85% of secondary leukemia associated with anticancer agents of topoisomerase II inhibitors.[12],[13]

Cytogenetic analysis is one of the most important diagnostic tools for determining the prognosis in hematologic malignancies, particularly ALL. Therefore, the diagnosis of chromosomal abnormalities, including deletion, duplication, and inversion, has strong prognostic value in choosing appropriate treatment, recovery strategy, and clinical approach to these patients.[14],[15] Furthermore, genetic diagnosis in these patients is an important factor in genetic counseling that could predict the risk of subsequent offspring with greater accuracy.[16]

The present study was aimed to investigate the prognostic value and diagnostic accuracy of 11q23 translocation and its relationship with other prognostic factors such as age, sex, and therapeutic response in childhood ALL.

 Patients and Methods



Study design

This prospective study was conducted on 100 children with ALL who were referred to Ahvaz Shafa Hospital, Ahvaz, Iran during 2012–2017. This study was approved by the local ethics committee of Ahvaz Jundishapur University of Medical Sciences, which were in complete accordance with the ethical standards and regulations of human studies of the Helsinki declaration (2014). Before the enrollment, the experimental procedures, objectives, possible benefits, and adverse effects of the study were clearly explained to all participants, and then all participants filled and signed a written consent form for their participation in the study.

Participants

Children diagnosed with ALL, according to morphologic and flow cytometric findings, are provided by a specialist physician specializing in bone marrow testing and are introduced for karyotyping and cytogenetic testing, were enrolled. Besides, the bone marrow sample is obtained on the 7th day of the chemotherapy and bone marrow samples (amount to 5 ml) were collected using a heparinized complete blood count (CBC) glass. Then, the collected samples were sent to the laboratory for karyotype and cytogenetic testing.

Methods

Preparation of chromosomes is performed by peripheral blood culture with phytohemagglutinin mitogen or by bone marrow culture on lam, which was the same as the karyotyping technique in the patients. The obtained chromosomes were then stained with Giemsa color and then denatured with trypsin. Then, at the end of the first step, mitotic analysis was performed to detect various numerical and structural chromosome abnormalities. In the second step, these chromosomes were combined with the probe in a humidified incubator for 10 min and at a temperature of 80°C–75°C to be denatured. Then, after washing, the probe and the chromosome were brushed. In the final step, a special fluorescence color the staining was used and depending on the selected color; the background was stained with a color and chromosome in the opposite color. The fluorescence in situ hybridization (FISH) technique was applied to slides that were not stained and analyzed by cytogenetics.

Statistical analysis

In this study, descriptive indexes, such as mean, interquartile, range, and standard deviation, were used to describe the quantitative variables (age and WBC). Frequency and frequency were used to describe the qualitative variable such as gender. Normality of quantitative variables was evaluated using Shapiro–Wilk test. Single-variable analysis was used to examine the relationship between quantitative and gender variables with cytogenetic status using Mann–Whitney nonparametric test (in cases of nonnormality of the quantitative variables assessed by Mann–Whitney test) and Chi-square test. In addition, multivariate analysis of data was performed using logistic regression model. To evaluate the molecular testing diagnostic function in distinguishing between negative and positive 11q23 translocation of diagnostic measures such as sensitivity, specificity, positive, and negative predictive value, accuracy, Youden's Index, positive and negative likelihood ratio, and area under the receiver operating characteristic (ROC) curve (area under the curve [AUC]) area under the ROC curve. In this study, the statistical analyses were performed with R programming (version 3.03). In all statistical analyzes, the significance level was set at 0.05.

 Results



From 100 children with ALL, 86 cases (86%) were pre-B-lineage and 14 cases (14%) were T-lineage subtype [Table 1]. t(9, 22) breakpoint cluster region-Abelson murine leukemia (p190) (6%) was the most frequent cytogenetic abnormalities in patients with ALL [Table 1].{Table 1}

Molecular and cytogenetic findings in patients with ALL are presented in details [Table 2]. Using FISH on 31 patients were positive in terms of the 11q23 translocation [Table 2]. There was no relationship between the 11q23 translocation and gender [Table 3]. Results showed no difference between the age of children and positive or negative 11q23 translocation (P = 0.6). Moreover, the mean WBC counts in the patients who were negative or positive for 11q23 translocation revealed a statistically significant relationship between WBC count and 11q23 translocation (P = 0.022).{Table 2}{Table 3}

The diagnostic accuracy of clinical parameters and a positive 11q23 translocation could verify the clinical suspicion of ALL. In this regard, molecular findings increased the prediction sensitivity of the 11q23 translocation to 90% (95% confidence interval [CI] = 74%–98%, [Table 3]).

The corresponding ROC curve for molecular findings compared with cytogenetic analysis is presented in [Figure 1]. As expected, the diagnostic accuracy for 11q23 translocation detection with functional significance by molecular findings, compared with the cytogenetic data as the reference, was 84.9% [Figure 1]; AUC = 0.849, 95% CI: 0.776–0.921].{Figure 1}

 Discussion



ALL is a common disease in children that is associated with various pathogenesis. The occurrence of mutations and genetic translocations are one of the main pathogenic causes of the disease.[17],[18] Recent studies have shown that the occurrence of translocations in ALL patients in response to therapeutic agents is important in responding to patient treatment and controlling the progression of the disease.[17] On this basis, it has been shown that some of the translocations such as t(12; 21) that produce the ETV-RUNX-1 fusion are accompanied by strong prognosis, while 11q23 translocation is with poor prognosis and associated with disease progression.[19] The findings of the present study showed that integrating functional data including cytogenetic assessment, from diverse modalities increases diagnostic accuracy. The present study reported a significant association between 11q23 translocation and absence of preliminary response to chemotherapy and WBC counts; however, the associations between 11q23 translocation and other variables such as gender and age, were not statistically significant, which could be attributed to the small sample size of this study.

Motlló et al. investigated the relationship between 11q23 translocation and its prognostic value in ALL patients. They reported no relationship between the 11q23 translocation with age, sex, and WBC of the patients.[20] Moreover, Pigneux et al. showed that AML patients with 11q23 translocation did not show complete treatment response and thus disease improvement. They concluded that bone marrow transplantation is necessary in these patients.[21] In addition, a study by Zuo et al. reported that patients with myelodysplastic syndrome with 11q23 translocation were resistant to treatment and showed disease recurrence, and the disease progression to AML was accelerated.[22] Basically, gender does not play a crucial role at AML incidence, particularly among the children.[23] Former studies on the role of age in AML incidence, have reported that increasing age was associated with elevated AML incidence, particularly during infancy.[24] A synthetic analysis of large population on several trials on the diagnostic value of cytogenetic abnormalities on treatment outcome in leukemia, provided the framework for stratifying treatment method of the disease, which has been adopted in the recent trials.[25] A large series of consecutive analyses on patients with leukemia using FISH and multiplex-FISH (M-FISH) techniques reported the sensitivity of conventional cytogenetic methods as 73%, compared with FISH. In conclusion, the authors recommended cytogenetic analysis be complemented by molecular or FISH methods to unravel leukemia rearrangements.[26] Another retrospective study with large sample size of children with leukemia revealed that diagnostic accuracy of cytogenetic approach combined with molecular techniques for detecting 11q23 translocation is generally high, whereas the sensitivity is not optimal for all anomalies.[27] In agreement with these findings, our study reported accuracy of about 85% for combined molecular and cytogenetic methods.

 Conclusion



Leukemia rearrangements could be associated with poor outcome in pediatric patients with ALL. Moreover, a significant association between 11q23 translocation and primary response to chemotherapy exists, but no correlation was observed between this translocation with age or gender of the patients. Therefore, conducting further studies using molecular and cytogenetic tests are necessary to support these findings. Diagnostic accuracy of these tests for detecting 11q23 translocation is generally high and also sensitivity and specificity are optimal for all anomalies.

Acknowledgments

This paper is issued from the thesis of Arash Alghasi, pediatric hematology and oncology graduate. This work was financially supported by Vice-chancellor for Research Affairs in Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Grant no.: TH91/02).

Financial support and sponsorship

This work was financially supported by Vice-chancellor for Research Affairs in Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Grant no.: TH91/02).

Conflicts of interest

There are no conflicts of interest.

References

1Caughey RW, Michels KB. Birth weight and childhood leukemia: A meta-analysis and review of the current evidence. Int J Cancer 2009;124:2658-70.
2Esparza SD, Sakamoto KM. Topics in pediatric leukemia – Acute lymphoblastic leukemia. Med Gen Med 2005;7:23.
3Chiaretti S, Zini G, Bassan R. Diagnosis and subclassification of acute lymphoblastic leukemia. Mediterr J Hematol Infect Dis 2014;6:e2014073.
4Krajinovic M, Labuda D, Sinnett D. Childhood acute lymphoblastic leukemia: Genetic determinants of susceptibility and disease outcome. Rev Environ Health 2001;16:263-79.
5Campana D, Coustan-Smith E. Measurements of treatment response in childhood acute leukemia. Korean J Hematol 2012;47:245-54.
6Hussaini M. Biomarkers in hematological malignancies: A review of molecular testing in hematopathology. Cancer Control 2015;22:158-66.
7Kumar CC. Genetic abnormalities and challenges in the treatment of acute myeloid leukemia. Genes Cancer 2011;2:95-107.
8Raynaud SD, Dastugue N, Zoccola D, Shurtleff SA, Mathew S, Raimondi SC. Cytogenetic abnormalities associated with the t(12;21): A collaborative study of 169 children with t(12;21)-positive acute lymphoblastic leukemia. Leukemia 1999;13:1325-30.
9Malouf C, Ottersbach K. Molecular processes involved in B cell acute lymphoblastic leukaemia. Cell Mol Life Sci 2018;75:417-46.
10Jaso J, Thomas DA, Cunningham K, Jorgensen JL, Kantarjian HM, Medeiros LJ, et al. Prognostic significance of immunophenotypic and karyotypic features of Philadelphia positive B-lymphoblastic leukemia in the era of tyrosine kinase inhibitors. Cancer 2011;117:4009-17.
11Mrózek K, Harper DP, Aplan PD. Cytogenetics and molecular genetics of acute lymphoblastic leukemia. Hematol Oncol Clin North Am 2009;23:991-1010, v.
12Godley LA, Larson RA. Therapy-related myeloid leukemia. Semin Oncol 2008;35:418-29.
13Bhatia S. Therapy-related myelodysplasia and acute myeloid leukemia. Semin Oncol 2013;40:666-75.
14Haase D, Hanf V, Schulz T. Therapy-related hematologic neoplasias after breast cancer. Epidemiologic, etiologic and cytogenetic aspects and new risk factors according to published data and own results. Med Klin (Munich) 2004;99:506-17.
15Gulley ML, Shea TC, Fedoriw Y. Genetic tests to evaluate prognosis and predict therapeutic response in acute myeloid leukemia. J Mol Diagn 2010;12:3-16.
16Moyer VA, U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive services task force recommendation statement. Ann Intern Med 2014;160:271-81.
17Alqasi A, Tavakolifar Y, Rezaeeyan H, Saki N, Bagherpour S, Nasab MA. Cytogenetic and molecular assessment of childhood acute lymphoblastic leukemia patients from 2014 to 2017 in Ahvaz. Clin Cancer Investig J 2019;8:28.
18Eyvazi S, Kazemi B, Dastmalchi S, Bandehpour M. Involvement of CD24 in multiple cancer related pathways makes it an interesting new target for cancer therapy. Curr Cancer Drug Targets 2018;18:328-36.
19Ampatzidou M, Papadhimitriou SI, Paterakis G, Pavlidis D, Tsitsikas K, Kostopoulos IV, et al. ETV6/RUNX1-positive childhood acute lymphoblastic leukemia (ALL): The spectrum of clonal heterogeneity and its impact on prognosis. Cancer Genet 2018;224-225:1-1.
20Motlló C, Ribera JM, Morgades M, Granada I, Montesinos P, Brunet S, et al. Frequency and prognostic significance of t(v; 11q23)/KMT2A rearrangements in adult patients with acute lymphoblastic leukemia treated with risk-adapted protocols. Leuk Lymphoma 2017;58:145-52.
21Pigneux A, Labopin M, Maertens J, Cordonnier C, Volin L, Socié G, et al. Outcome of allogeneic hematopoietic stem-cell transplantation for adult patients with AML and 11q23/MLL rearrangement (MLL-r AML). Leukemia 2015;29:2375-81.
22Zuo W, Wang SA, DiNardo C, Yabe M, Li S, Medeiros LJ, et al. Acute leukaemia and myelodysplastic syndromes with chromosomal rearrangement involving 11q23 locus, but not MLL gene. J Clin Pathol 2017;70:244-9.
23Jenney ME. Principles and practice of pediatric oncology. Arch Dis Child 1994;70:73.
24Appelbaum FR, Gundacker H, Head DR, Slovak ML, Willman CL, Godwin JE, et al. Age and acute myeloid leukemia. Blood 2006;107:3481-5.
25Grimwade D, Walker H, Oliver F, Wheatley K, Harrison C, Harrison G, et al. The importance of diagnostic cytogenetics on outcome in AML: Analysis of 1,612 patients entered into the MRC AML 10 trial. The medical research council adult and children's leukaemia working parties. Blood 1998;92:2322-33.
26Cox MC, Panetta P, Lo-Coco F, Del Poeta G, Venditti A, Maurillo L, et al. Chromosomal aberration of the 11q23 locus in acute leukemia and frequency of MLL gene translocation: Results in 378 adult patients. Am J Clin Pathol 2004;122:298-306.
27Olde Nordkamp L, Mellink C, van der Schoot E, van den Berg H. Karyotyping, FISH, and PCR in acute lymphoblastic leukemia: Competing or complementary diagnostics? J Pediatr Hematol Oncol 2009;31:930-5.