Sequential acquisition of IgH and TCR rearrangements during the preleukemic phase of acute lymphoblastic leukemia in an adolescent patient.

Acute lymphoblastic leukemia (ALL) can be preceded by a prodromal phase of bone marrow failure. In serial trephine biopsies in a girl with acquired bone marrow hypoplasia, we have identified a monoclonal B-cell precursor population characterized by a clone-specific IgH-FR3 gene rearrangement. Progression to ALL more than 4 months later was accompanied by acquisition of an additional T-cell receptor rearrangement. Thus, hypoplastic pre- and overt leukemia share a common clonal origin. Prospective biobanking and extended molecular analysis can help to better understand the nature and sequence of genetic events during progression of a covert (pre)leukemic clone.

Defining the oncogenic function of the TEL/AML1 (ETV6/RUNX1) fusion protein in a mouse model.

The t(12;21) translocation, generating the TEL/AML1 fusion protein, is the most common genetic lesion in childhood cancer. Using a bone marrow transplantation model, we demonstrate that TEL/AML1 expression impinges on normal hematopoietic differentiation, leading to the in vivo accumulation and persistence of an early progenitor compartment with a Sca1(+)/Kit(hi)/CD11b(+) phenotype and an increased self-renewal capacity, as documented by replating assays in vitro. Differentiation of these cells is not blocked, but the frequency of mature blood cells arising from TEL/AML1-transduced progenitors is low. Impaired differentiation is prominently observed in the pro-B-cell compartment, resulting in an proportional increase in early progenitors in vivo, consistent with the t(12;21) ALL phenotype. Despite the accumulation of both multipotent and B-cell progenitors in vivo, no leukemia induction was observed during an observation period of over 1 year. These results are consistent with findings in twins with concordant ALL, showing that TEL/AML1 generates a preleukemic clone in utero that persists for several years in a clinically covert fashion. Furthermore, our studies showed that the pointed domain of TEL/AML1, which recruits transcriptional repressors and directs oligomerization with either TEL/AML1 or wild-type TEL, was essential for the observed differentiation impairment and could not be replaced with another oligomerization domain.

Disruption of hematopoiesis and thymopoiesis in the early premalignant stages of infection with SL3-3 murine leukemia virus.

A time course analysis of SL3-3 murine leukemia virus (SL3) infection in thymus and bone marrow of NIH/Swiss mice was performed to assess changes that occur during the early stages of progression to lymphoma. Virus was detectable in thymocytes, bone marrow, and spleen as early as 1 to 2 weeks postinoculation (p.i.). In bone marrow, virus infection was detected predominantly in immature myeloid or granulocytic cells. Flow cytometry revealed significant reductions of the Ter-119(+) and Mac-1(+) populations, and significant expansions of the Gr-1(+) and CD34(+) populations, between 2 and 4 weeks p.i. Analysis of colony-forming potential confirmed these findings. In the thymus, SL3 replication was associated with significant disruption in thymocyte subpopulation distribution between 4 and 7 weeks p.i. A significant thymic regression was observed just prior to the clonal outgrowth of tumor cells. Proviral long terminal repeats (LTRs) with increasing numbers of enhancer repeats were observed to accumulate exclusively in the thymus during the first 8 weeks p.i. Observations were compared to the early stages of infection with a virtually nonpathogenic SL3 mutant, termed SL3DeltaMyb5, which was shown by real-time PCR to be replication competent. Comparison of SL3 with SL3DeltaMyb5 implicated certain premalignant changes in tumorigenesis, including (i) increased proportions of Gr-1(+) and CD34(+) bone marrow progenitors, (ii) a significant increase in the proportion of CD4(-) CD8(-) thymocytes, (iii) thymic regression prior to tumor outgrowth, and (iv) accumulation of LTR enhancer variants. A model in which disrupted bone marrow hematopoiesis and thymopoiesis contribute to the development of lymphoma in the SL3-infected animal is discussed.

Role of mononuclear phagocyte system in hemopoiesis regulation in AKR/JY mice during preleukemic period.

Feeder activity of bone marrow adherent cells and peritoneal macrophages is decreased and colony-stimulating and erythropoietic activity of unfractionated bone marrow increased in highly leukemic AKR/JY mice in comparison with CBA/CaLac mice. At the same time maturation of hemopoietic precursor cells in AKR/JY mice is delayed compared to controls. This indicates compensatory activation of nonadherent elements of the hemopoiesis-inducing microenvironment against the background of suppressed activity of adherent elements. Hence, leukemogenic virus produced a systemic damage to target cells (e.g. mononuclear phagocyte system), which probably represent a mechanism of leukemic transformation in AKR/JY mice.

Shwachman-Diamond syndrome: An inherited preleukemic bone marrow failure disorder with aberrant hematopoietic progenitors and faulty marrow microenvironment.

Shwachman-Diamond syndrome (SD), an inherited disorder with varying cytopenias and a marked tendency for malignant myeloid transformation, is an important model for understanding genetic determinants in hematopoiesis. To define the basis for the faulty hematopoietic function, 13 patients with SD (2 of whom had myelodysplasia with a clonal cytogenetic abnormality) and 11 healthy marrow donors were studied. Patients with SD had significantly lower numbers of CD34(+) cells on bone marrow aspirates. SD CD34(+) cells plated directly in standard clonogenic assays showed markedly impaired colony production potential, underscoring an intrinsically aberrant progenitor population. To assess marrow stromal function, long-term marrow stromal cell cultures (LTCs) were established. Normal marrow CD34(+) cells were plated over either SD stroma (N/SD) or normal stroma (N/N); SD CD34(+) cells were plated over either SD stroma (SD/SD) or normal stroma (SD/N). Nonadherent cells harvested weekly from N/SD LTCs were strikingly reduced compared with N/N LTCs; numbers of granulocyte-monocyte colony-forming units (CFU-GM) derived from N/SD nonadherent cells were also lower. SD/N showed improved production of nonadherent cells and CFU-GM colonies compared with SD/SD, but much less than N/N. Stem-cell and stromal properties from the 2 patients with SD and myelodysplasia did not differ discernibly from SD patients without myelodysplasia. We conclude that in addition to a stem-cell defect, patients with SD have also a serious, generalized marrow dysfunction with an abnormal bone marrow stroma in terms of its ability to support and maintain hematopoiesis. This dual defect exists in SD with and without myelodysplasia.

[Myelodysplastic syndromes: preleukemic syndromes]. / Les syndromes myélodysplasiques: syndromes préleucémiques.

The myelodysplastic syndromes (MDS) are a heterogeneous group of disorders characterized by peripheral blood cytopenias with a hypercellular bone marrow exhibiting dyspoiesis. The predominant in elderly patients are associated with a high risk of progression to acute myelogenous leukemia. The etiology of MDS is unknown in most cases. About 10% of MDSs are secondary. MDS are classified by the French American British (FAB) classification into five subgroups. The incidence of the disorders is difficult to estimate but it seems to be increasing. Clonal cytogenetic aberrations are found in 30 to 50% of de novo MDS. The only currative treatment for MDS is allogeneic bone marrow transplantation.

Clinical course of human T-lymphotropic virus type I carriers with molecularly detectable monoclonal proliferation of T lymphocytes: defining a low- and high-risk population.

To characterize the prodromal phase of adult T-cell leukemia (ATL), a prospective follow-up study was conducted on 50 carriers in a putative pre-ATL state. This state was defined by the presence of molecularly-detectable monoclonal proliferation of human T-lymphotropic virus type I (HTLV-I)-infected T lymphocytes, and the absence of clinical symptoms of leukemia. The median observation time was 50 months. The pre-ATL subjects were divided into two groups according to initial white blood cell (WBC) counts: group A, those with a normal WBC count (9,000/microL) (n = 30), and group B, those with an increased WBC count (9,000 to 15,000) (n = 20). Comparisons were made between the two groups and with a group of 25 patients with chronic ATL (group C) who had WBC counts of more than 15,000. Significant differences in survival rate were found between groups A and B (10-year survival 65.7%) and group C (32.8%) (P < .01), and between group A (10-year survival 90.0%) and group B (52.1%) (P < .05). The incidence of transformation to overt ATL was 10% (3 of 30) in group A and 50% (10 of 20) in group B (P < .01). In six transformed cases (one in A and five in B) we found exactly the same integration sites in pre-ATL and overt ATL phases, confirming the multistep leukemogenesis hypothesized for this disease. However, the pre-ATL subjects could be divided into two distinct prognostic groups based on the initial WBC count; those with good and those with poor prognosis. Although the 10% transformation rate (2.5% annually) in group A seemed to be extremely high compared with that in the general population of HTLV-I carriers (around 0.06% to 0.4% annually), the majority of group A subjects and some in group B showed stable clinical courses without transformation. Further, development of ATL was not observed in four group A subjects with HTLV-I-associated myelopathy (HAM), which is rarely associated with ATL. We propose to call this group of rather benign HTLV-I carriers "HTLV-I carriers with monoclonal proliferation of T lymphocytes (HCMPT)." Thus far we have been unable to identify reliable parameters other than WBC counts that prospectively distinguish HCMPT from the true pre-ATL state, in which there is a high probability of developing ATL. Further clinical and biologic approaches should elucidate the natural history of the HTLV-I carrier state and early events in ATL leukemogenesis.

Growth hormone treatment and development of malignancy: recombinant human growth hormone does not induce leukemia in AKR/O-mice.

In 1988 several reports described leukemia in former/present growth hormone (GH)-treated children, and a doubled incidence of leukemia in GH-treated children was concluded in a workshop in Bethesda. A mouse strain (AKR/O) with a high incidence of leukemia was used as a model. AKR/O-mice in the preleukemic adult age and younger mice during rapid growth were treated with recombinant human GH (rhGH) in human therapeutic doses to see whether this treatment would affect the time and presentation of malignant disease. The malignant development did not appear earlier or in a different way in the animals receiving rhGH from day 6 to 50 than in their appropriate controls. A borderline protective effect to the development of leukemia was seen in the adult group receiving rhGH; in this group antibodies to hGH also developed. We conclude that in this experimental model human therapeutic doses of rhGH do not influence the development of malignancy in the AKR/O mice.

Induction of IL-4 secretion by the radiation leukemia virus (RadLV): role in autocrine growth stimulation of RadLV infected pre-leukemic cells.

Intrathymic inoculation of radiation-leukemia virus (RadLV) into C57BL/6 mice induces a population of pre-leukemic (PL) T cells which progress into clonal, mature thymic lymphomas after a latency period of 3 to 5 months. In order to understand how PL cells are retained in the thymus for a prolonged period of time we determined whether RadLV infected cells secrete and/or respond to a T-cell growth factor that may be involved in the long-term maintenance of a thymic PL-cell pool. We have previously found that in vitro proliferation of RadLV-infected PL cells is IL-4-dependent. Here we show that RadLV induces IL-4 secretion and IL-4 receptor (IL-4R) expression in normal thymic lymphocytes. RadLV-infected PL thymocytes express IL-4R and secrete IL-4. Their IL-4 secretion could be enhanced if incubated in the presence of RadLV and this enhancement was inhibited by anti-RadLV antibodies. Several RadLV-induced lymphoma lines secreted IL-4 and/or expressed IL-4R, but these features were not essential for their continuous growth. The results suggest that RadLV induces IL-4-dependent autocrine growth which maintains a population of PL T cells in the thymus. Transition from a PL state to overt thymic lymphoma involves emancipation of a PL cell from IL-4 dependency.

Growth modulation of human leukemic, preleukemic, and myeloma progenitor cells by L-ascorbic acid.

L-Ascorbic acid (LAA) was shown to modulate the in vitro growth of colonies of human and mouse myeloma progenitor-stem cells through use of a unique cell-culture assay. LAA was also shown to modulate the in vitro growth of leukemic colony-forming cells (L-CFC) from bone marrow of patients with acute myelocytic leukemia. LAA enhanced the growth of L-CFC in 35% of patients and suppressed the growth of L-CFC in 15% of patients. The minimum effective concentration was 0.03 mmol/L. The modulating effect is specific to LAA because other redox compounds are without effect. From the cell kinetic standpoint, the LAA effect is cytostatic rather than cytocidal. Similar LAA effects have prognostic value in patients with myelodysplastic syndromes (MDS), with LAA-sensitive patients displaying shorter survival than LAA-insensitive patients. MDS appears to be the ideal disease for clinical trials involving in vivo LAA manipulation to control the disease process.

In vitro modulation of normal and diseased human neutrophil function by pentoxifylline.

The influence of pentoxifylline on normal and diseased neutrophil function has been studied in vitro. In high concentrations pentoxifylline stimulated human neutrophil chemotaxis toward both bacterial oligopeptides and complement components. Pentoxifylline was also shown in vitro to restore the normal chemotactic capacity of neutrophils from patients with known functional defects, i.e. myelodysplastic syndromes, lazy leucocyte syndrome, juvenile parodontitis, hyper-IgE-syndrome and liver cirrhosis. Pentoxifylline was also shown to strongly inhibit the release of primary and secondary granule release of granulocytes. Moreover, pentoxifylline inhibits both basal and stimulated neutrophil adhesion to both aortic and pulmonary artery calf endothelium. The mechanism whereby pentoxifylline exerts this action is not adequately understood. While our results partially imply interference of pentoxifylline with neutrophil cyclic AMP and/or prostaglandin metabolism, down-regulation of neutrophil functional antigen (e.g. CD11, CD18) expression seems to play a key role in the observed drug effects. Finally, these results indicate that pentoxifylline may be useful in the treatment of granulocyte mediated diseases and symptoms.

Preleukaemia and myelodysplastic syndromes today.

The clinical picture of myelodysplastic syndromes (MDS) results from the expansion of an abnormal clone of haemopoietic stem cells that has undergone premalignant transformation. Different types of "oncogene" may be involved in this process, some of which code for growth factors and their receptors, some for membrane or cytoplasmic proteins and some for nuclear binding proteins. The insults causing gene mutations are not known, though chemical, viral or radiation damage could be important. The most striking feature of MDS is the inadequate production of dysplastic, poorly functional cells as a result of impaired differentiation and premature cell death in the bone marrow. Treatment is currently directed to supportive therapy with blood components and antibiotics, attempts to stimulate proliferation and differentiation with recombinant human growth factors, and, in a few cases, bone marrow transplantation. Chemotherapy alone has met with little success.

[Preleukemic disorders].

Certain hematopoietic disorders and immunodeficiency states are known to carry a risk of developing acute nonlymphocytic leukemia. In the past some of them have been classified by a variety of terms ranging from refractory anemia to preleukemia, but are currently grouped into a new concept of the myelodysplastic syndromes (MDS). The purpose of this article is to briefly review the updated knowledge of the MDS with emphasis on the clonal origin, natural history and mechanisms of leukemogenesis.

[Induction of myelogenous differentiation: a therapeutic possibility for preleukemia and acute leukemia?]. / Induktion der myeloischen Differenzierung: eine therapeutische Möglichkeit für Präleukämien und akute Leukämien?

Human acute myelogenous leukemia often arises from a transformation at the stem cell level leading to a block in differentiation. The malignant cell, therefore, remains in the proliferative pool and rapidly accumulates. In preleukemia, also known as myelodysplastic syndromes, the malignant clone is already established, leading to disturbed hematopoiesis. One therapeutic approach, therefore, might be to overcome this block in differentiation and thus shift the cell from the proliferative into the differentiating pool. For several years now research in leukemia has focused on study of the proliferation and differentiation of normal and leukemic hematopoietic cells. Numerous substances have been identified which are able to trigger differentiation in myeloid cells, including the retinoids, vitamin D, tumor necrosis factor and hematopoietic hormones. The possible role of these agents in the treatment of preleukemia and acute myelogenous leukemias is discussed.

Adult T cell leukemia-like disease experimentally induced in rabbits.

An HTLV-I-transformed T cell line, obtained from the peripheral blood of a virus-infected (B/J X Chbb:HM) F1 rabbit, was able to kill syngeneic newborn rabbits within 7 days, when inoculated intraperitoneally at a dose of 1 X 10(8) cells. Inoculation of 1 X 10(7) cells killed or rendered moribund 50% of inoculated animals, while surviving animals exhibited cell-mediated cytotoxic activities against the transformed cells. The peripheral blood leukocyte counts increased in all surviving animals, in association with appearance of abnormal lymphocytes with convoluted or lobulated nuclei. Pathological examination of animals that died one week post-inoculation revealed no tumors in the abdominal cavity, but accumulation of ascites containing abnormal lymphocytes. Histological examination showed leukemic infiltration in the liver, lungs, spleen and mesenteric lymph nodes. The same cell line was also able to kill syngeneic adult rabbits in 8-10 days when inoculated intravenously, but not intraperitoneally, at a dose of 1 X 10(8) cells. Leukemic infiltration was observed in the major organs of these animals. Adult animals which were already virus carriers were resistant to this lethal inoculation. This rabbit ATL-like disease may prove to be useful as an experimental model for acute adult T cell leukemia.