Trisomy 11 in Myelodysplastic Syndromes Defines a Unique Group of Disease with Aggressive Clinicopathologic Features

Trisomy 11 in myelodysplastic syndromes deﬁnes a unique group of disease with aggressive clinicopathologic features

SA Wang1, K Jabbar1,GLu1, SS Chen1, N Galili2, F Vega1, D Jones1, A Raza2, H Kantarjian3, G Garcia-Manero3, TJ McDonnell1 and LJ Medeiros1

1Department 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 exons in a 50–30 direction spanning mainly exons 2–6 or 2–8. undefined clinical significance and is currently assigned to the Although variable, each of the distinct fusion transcripts International Prognostic Scoring System (IPSS) intermediate- risk group. Over a 15-year period, we identified 17 MDS patients resulting from MLL PTD has been in frame and encodes the with trisomy 11 either as a sole abnormality (n ¼ 10) or N-terminal region of MLL leading to a potentially translatable associated with one or two additional alterations (n ¼ 7), sequence. comprising 0.3% of all MDS cases reviewed. Of 16 patients Myelodysplastic syndromes (MDS) or myelodysplastic/myelo- with Bone Marrow material available for review, 14 (88%) proliferative neoplasms (MDS/MPN) with trisomy 11 as a sole patients presented with excess blasts, 69% patients evolved abnormality or as part of a noncomplex karyotype are rare, and to acute myeloid leukemia (AML) in a 5-month median interval 6–12 and the median survival was 14 months. For comparison, we only sporadic cases have been reported in the literature. The studied 19 AML patients with trisomy 11 in a noncomplex clinicopathologic aspects of this neoplasm are not well defined, karyotype, of which, a substantial subset of patients had largely because of the rarity of this abnormality compared with morphologic dysplasia, and/or preexisting cytopenia(s)/MDS. other well-characterized cytogenetic alterations in MDS and Genomic DNA PCR showed MLL partial tandem duplication in 5 MDS/MPN. According to the 1997 International Prognostic of 10 MDS and 7 of 11 AML patients. A review of literature Scoring System (IPSS),13 trisomy 11 is grouped together with identified 17 additional cases of MDS with trisomy 11, showing similar clinicopathologic features to our patients. Compared other miscellaneous single chromosomal aberrations within the with our historical data comprising 1165 MDS patients, MDS intermediate-risk cytogenetic group. In a previous study 14 patients with trisomy 11 had a significantly inferior survival to consisting of 1029 primary (de novo) MDS patients, we patients in the IPSS intermediate-risk cytogenetic group identified four patients with MDS associated with trisomy 11 as (P ¼ 0.0002), but comparable to the poor-risk group (P ¼ 0.97). a sole abnormality. These patients appeared to have an We conclude that trisomy 11 in MDS correlates with clinical aggressive clinical course, compared with MDS patients with aggressiveness, may suggest an early/evolving AML with myelodysplasia-related changes and is best considered a other cytogenetic abnormalities considered as intermediate risk. high-risk cytogenetic abnormality in MDS prognostication. We suspected that trisomy 11, which has been shown to be Leukemia (2010) 24, 740–747; doi:10.1038/leu.2009.289; associated with high frequency of MLL PTD in AML patients, published online 14 January 2010 might carry the same molecular alteration in MDS. If true, the Keywords: myelodysplastic syndrome; trisomy 11; acute myeloid presence of trisomy 11 in MDS would be best considered as a leukemia; overall survival; MLL partial tandem duplication 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 Introduction 11 as a sole cytogenetic abnormality or as a part of a noncomplex karyotype, and compared these cases to 19 Trisomy 11 as a sole abnormality is an infrequent nonrandom patients with AML associated with trisomy 11. We studied the chromosomal aberration observed in acute myeloid leukemia clinicopathologic characteristics of these patients, and assessed (AML). AML with trisomy 11 has been shown to be associated for MLL PTD in cases with available DNA using PCR analysis, with a stem/progenitor cell immunophenotype with myeloid results were confirmed by Southern blot analysis in a subset of antigen expression, is not confined to a specific French– cases. A review of 17 cases reported in the literature, mostly in American–British (FAB) subtype and has been characterized by the form of case reports, is also provided. 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 Materials and methods trisomy 11, molecular analysis has shown that the MLL gene (also called ALL-1, HRX or Htrx) is frequently rearranged Patients through partial tandem duplication (PTD).3–6 The duplicated The files of the Department of Hematopathology at the region of the MLL gene consists of an in-frame repetition of University of Texas MD Anderson Cancer Center (MDACC), University of Massachusetts Memorial Medical Center and St Correspondence: Dr SA Wang, Department of Hematopathology, The Vincent’s Comprehensive Cancer Center from 1995 to the University of Texas MD Anderson Cancer Center, 1515 Holcombe beginning of the study were searched for patients with MDS or Boulevard, Houston, TX 77030-4009, USA. E-mail: [email protected] MDS/MPN with trisomy 11 as a sole abnormality or as part of a Received 9 November 2009; accepted 23 November 2009; published noncomplex karyotype. For comparison, 19 patients with AML online 14 January 2010 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 respectively, whereas HindIII digests were hybridized to the of the electronic medical records for any history of antecedent B859 probe, stripped and then hybridized to the SAS1 probe. chemotherapy, radiation therapy, hematologic neoplasm, cyto- Southern blotting, stripping, probe radiolabeling and autoradio- penia(s), treatment information and outcomes. This study was graphy were performed using standard techniques. approved by the institutional review boards of all the participating institutions. MDS and MDS/MPN cases were reclassified according to 2008 World Health Organization FLT3 and K- and N-RAS mutation analyses (WHO) classification criteria15 after pathology review and A fluorescence-based multiplex PCR assay was used to detect incorporation of molecular genetic information. Overall survival internal tandem duplication (ITD) and D835 point mutations of (OS) was measured from the day of diagnosis of MDS, MDS/ the FLT3 gene using DNA isolated from BM aspirate or 18 MPN or AML until death from any cause, censored for patients peripheral blood samples, as previously described. K-RAS known to alive till the last follow-up. The survival of patients and N-RAS mutations were tested using PCR followed by 19 with MDS associated with trisomy 11 was compared to that in pyrosequencing as described previously. our historical database consisting of 1165 MDS patients treated by the same group of hematologists between 1995 and 2006. Literature review All published cases in the English literature with a confirmed Morphologic evaluation diagnosis of MDS or MDS/MPN associated with trisomy 11 were All patients had representative bone marrow (BM) aspirate reviewed in PubMed. The clinicopathologic characteristics, smears and trephine biopsy specimens available for evaluation. including patient demographic information, BM findings, A 500-cell BM differential count was performed based on frequency and interval of AML transformation, and OS were examination of multiple fields of the aspirate smears. For the summarized and analyzed. diagnosis of morphologic dysplasia in BM, features of dysery- thropoiesis, dysgranulopoiesis and dysmegakaryopoiesis had to Statistical analysis be present in X10% of cells of the respective lineage, as 15 Mann–Whitney test was used for numerical comparison specified in the 2008 WHO classification. In AML cases, between two groups. Fisher’s exact test and w2-test were applied aspirate smears were specifically assessed for Auer rods, for categorical variables. Patient survival was estimated by the granulocytic differentiation and morphologic evidence of Kaplan–Meier method from the date of BM diagnosis until death dysplasia in maturing elements. To allow for comparison with from any cause or until the last patient follow-up. Survival cases reported previously in the literature, we also classified curves were statistically compared by the log-rank test. cases using the FAB classification criteria. 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 Results laboratories using standard methods with minor differences in technique. In all cases, G-banded metaphase cells were Clinical characteristics of patients with myelodysplastic prepared from unstimulated BM aspirate cultures using standard syndromes or myelodysplastic/myeloproliferative techniques. Twenty metaphases were analyzed in all cases, if neoplasms associated with trisomy 11 available, and the results reported using the International System A total of 42 patients with a confirmed diagnosis of MDS or for Human Cytogenetic Nomenclature. In some cases a lesser MDS/MPN with trisomy 11 were identified from our database number of metaphases were available, but in all cases the consisting of approximately 5000 MDS and MDS/MPN cases. In numbers of metaphases were adequate to issue a karyotype. 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 Molecular studies karyotypes including trisomy 11 at the time of either transforma- DNA preparation and standard PCR in detection of MLL tion of AML or relapse of AML; 6 (24%) patients were partial tandem duplications. Mononuclear cells obtained considered to have therapy-related MDS (t-MDS) and 5 (20%) from BM aspirate specimens were isolated by Ficoll–Hypaque patients presented with refractory anemia with excess blasts gradient centrifugation and genomic DNA was extracted using a (RAEB). Owing to the complexity of these karyotypic abnorm- standard isolation procedure.16 PCR was performed according 3 alities in which the significance of trisomy 11 is obscured, these to the methods described by Caligiuri et al. using the primer cases were excluded from the final analysis. As a result, the 0 0 sets 6.1 (5 -GTCCAGAGCAGAGCAAACAG-3 ) from exon 6 study group included 17 patients with MDS (n ¼ 16) or MDS/ 0 0 (sense orientation) and 2.0R (5 -CGCACTCTGACTTCTTCATC-3 ) MPN (n ¼ 1) who had trisomy 11 either as a sole abnormality, or from exon 2 (antisense orientation). In brief, PCR was performed associated with one or two other abnormalities (Table 1). The on genomic DNA using Taq Extender PCR additive (Stratagene, overall frequency is approximately 0.3% of all MDS patients. La Jolla, CA, USA) according to the manufacturer’s instructions. Patient 3 in the study group had a history of chronic 1 1 The reactions were for 35 cycles (95 C for 1 min, 60 C for 1 min lymphocytic leukemia treated with chemotherapy (t-MDS). 1 1 and 72 C for 3.5 min), followed by a 10 min extension at 72 C. The remaining 16 patients had no history of malignancies and were considered as primary (de novo) MDS or MDS/MPN. The Southern blot analysis. Approximately 6 mg of genomic 17 patients in the study group included 13 men and 4 women DNA was digested to completion with BamHI. HindIII or EcoRI with a median age of 75 years (range, 47–85). The median restriction enzymes. Probes for Southern blot hybridization, hemoglobin was 9.4 g per 100 ml (range, 6.0–11.8), median designated B859 and SAS1,17 were used. The BamHI and EcoRI absolute neutrophil count 1.0 Â 109 per liter (range, 0.3–10.5) digests were hybridized with the B859 and SAS 1 probes, and median platelet count 105 Â 109 per liter (range, 3–269).

Leukemia 742 Leukemia

Table 1 The clinicopathological, molecular genetic features of patients with MDS; MDS/MPN with trisomy 11

No Other relevant Age BM BM 2008 WHO Cytogenetics Disease progression and Treatment, outcome, MLL PTD by Additional molecular (MR/ medical (years)/ cellularity%/ dysplasia classiﬁcation interval (months) survivala PCR studiesb name) history sex blast%

1 79/F 70/16 Myeloid, RAEB-2 47,XX,+11[18]/46,XX[2] AML, 13m No details of 5-Azacitidine, died, Not performed ND Erythroid the AML subtype. 19 months Mega 2 Crohn’s 76/F 75/14 Myeloid, RAEB-2 47,XX,+11[8]/46,XX[12] AML, 3m (FAB: RAEB-t, 5-Azacitidine for Positive KIT Negative disease Erythroid 28% blasts) RAEB-2; clofarabine FLT3 Negative Mega for AML, Died, 9 months 3 CLL, treated 70/F 90/0 Erythroid t-MDS 47,XY,+11[19]/46,XY[1] RAEB-2, followed by No treatment for MDS; Positive (at the RAS Negative with Mega AML, 9m (FAB-M4, 57% clofarabine for AML, time of AML) JAK2 Negative chemotherapy blasts) died, 10 months FLT3-D835 Mutation Positive at AML phase 4 62/M 85/8 Myeloid, RAEB-1 47,XY,+11[5]/46,XY[15] AML, 5m (FAB-M2, 30% MDS treatment Not performed Not performed Erythroid blasts) 47,XY,+11[20] unknown. Induction Mega chemotherapy for MDS in 11 Trisomy AML, died, 31 months 5 Low-grade 74/M 20/8 Myeloid, RAEB-1 47,xy,+11[15]/46,xy[5] AML, 3m (FAB-M2, 33% MDS treatment Not performed No t(8;21) Wang SA MDS, for 19 Erythroid blasts), unknown. Induction No inv(16) months, Mega chemotherapy for

without +11 AML, died, 48 months al et 6 50/F 35/6 Myeloid RAEB-1 47,xy,+11[8]/ AML, 5m (FAB-M2, Supportive care for Not performed Not performed Erythroid 48,xx,+2,+11[1]/46, 53% blasts) MDS, Induction xx[10] chemotherapy for AML, died, 8 months 7 76/M 90/9 Myeloid RAEB-1 47,XY,+11[9]/46,XY[11] RAEB-2, 10m Vadaza and Negative FLT3 Negative Erythroid thalidomide, died, 13 Mega months 8 81/M 50/3 Erythroid RCMD 47,XY,+11[2]/46,XY [20] RAEB-2, 6m, with Investigating agents for Negative FLT3 Negative Myeloid 47,XY,+11[17]/46, XY[3] MDS. Induction AML, 8m, with chemotherapy for 47,XY,+11[20] AML, died, 14 months 9 (RARS for 75/M 50/6 Erythroid RAEB-1 47, XY, +11[5]/46,XY[25] Lost follow-up Investigating agents for Negative FLT3 Negative 10 months, Mega MDS, died, 15 months normal karyotype) 10 85/M 70/13 Myeloid RAEB-2 48XY+8+11[44]/46,XY[2] No further BM biopsy Low-dose Not performed Not performed performed chemotherapy for MDS, died, 9 months 11 82/M 50/15 Erythroid CMML-2 49,XY,+8,+10,+11[18]/46, AML, 35m (FAB-RAEB-t, Chemotherapy for Not performed Not performed XY[2] 27% blasts) CMML-2; salvage chemotherapy for AML, died, 58 months 12 Cytopenia for 81/M 85/17 Erythroid RAEB-2 47,XY,+11[4]/46,XY[16] AML, 1m (FAB-RAEB-t, No chemotherapy, Positive (at time FLT3 ITD positive at 1 year, with Myeloid 29% blasts) investigating agents, of AML) the AML phase +8, no Megas died, 8 months dysplasia, 13 47/M 90/11 Erythroid RAEB-2 47,XY,+8, del(16)(q11.2) Decitabine for MDS, Positive RAS Negative Myeloid [9]/48,idem+11[7]/ followed by BMT. Alive, FLT3 Negative at MDS Megas 46,XY[4] 60 months and AML phases Trisomy 11 in MDS SA Wang et al 743 After diagnosis of MDS or MDS/MPN, patients received various treatments (Table 1), including supportive care, inves- tigational agents, thalidomide and derivatives, 5-azacitidine (Vidaza) and 5-aza-20-deoxycytidine (Decitabine). Complete

b clinical follow-up was available in 16 patients. With a median Negative Negative at MDS Negative Negative Negative follow-up interval of 13.5 months (range, 1–60 months, including alive and dead), 11 (69%) patients developed AML FLT3 Additional molecular studies RAS t(8;21) Neg RAS t(8;21) Negative RAS FLT3 and AML phases 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 Negative MLL PTD by PCR Negative Not performed Positive yelomonocytic leukemia; F, female; FAB, was 14 months.

on; RAEB, refractory anemia with excess blasts; Morphologic assessment and disease classiﬁcation The study group patients received the following diagnoses: one

a t-MDS, one refractory cytopenia with multilineage dysplasia (RCMD), one chronic myelomonocytic leukemia-2 (CMML-2); Investigating agents, alive, 12 months Induction chemotherapy, BMT, died of transplant- associated mortality, 30 months Treatment unknown, died, 5 months Treatment unknown, died, 1 month Treatment, outcome, survival 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; 25% blasts) AML, 1m (FAB-M2, 41% blasts), 48,XY,+8, +11[9]/ 46,XY[11] Continuously increased blasts (19%) No further BM biopsy performed interval (months) 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%. including ITD and D835 point mutation were specifically performed on all samples with available genomic For the 11 cases that transformed to AML, all were classified as AML with myelodysplasia-related changes (AML-MRC), FLT3 arising from preexisting MDS, using 2008 WHO classification criteria. According to FAB classification criteria, four were RAEB 47,XY,+11[20] AML, 2m (FAB-RAEB-t, 46,XY[15] 46,XY [11] 46,XY[3] Cytogenetics Disease progression and in transformation (RAEB-t), two were M1, four M2 and one M4 (Table 1). myelodysplastic syndromes; ND, not done; PTD, partial tandem duplicati

Cytogenetics Material not available for review RAEB-2 48,XY,+8, +11 [5]/ RAEB-2 47,XY,+8[5]/47,XY,+11[4]/ RAEB-2 49,XY,+11,+19,+22[16]/ 2008 WHO classiﬁcation 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), Myeloid Megas Myeloid Myeloid Megas Myeloid Megas BM dysplasia followed by other trisomies involving chromosomes 10, 2, 22

RCMD, refractory anemia with multilineage dysplasia. 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 blasts in blood) BM cellularity%/ blast% 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 77/M 45/7 (7% Age (years)/ sex transformation to AML. ) Acute myeloid leukemia with trisomy 11 abnormality A total of 19 patients who had AML with trisomy 11 in a 9 months, +8 Other relevant medical history Continued 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, Most of the tests were performed at the admission as part of the clinical work-up, only Survival was calculated from the time of MDS diagnosis with trisomy 11 abnormality to the last follow-up. 17 70/M not available Erythroid 15 68/M 30/17 Erythroid RARS, refractory anemia with ring sideroblasts; 16 RCMD French–American–British; ITD, internal tandem duplication; M, male; MDS, Table 1 No (MR/ name) 14 73/M 25/10Abbreviations: Erythroid AML, acute myeloid leukemia; BM, bone marrow; BMT, bonea marrow transplantation; CLL, chronicb lymphocytic leukemia; CMML, chronic m DNA. with a median age of 69 years (range, 33–89). Notably, two

Leukemia Trisomy 11 in MDS SA Wang et al 744 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 ) (1 and 3) maturation, one AML NOS myelomonocytic; two AML NOS

monoblastic; one AML NOS acute erythroid leukemia; and one FLT3

AML NOS megakaryoblastic leukemia. According to FAB 0.0001 (1 and 3) 0.96 (1 and 3) 0.24 ( 0.34 (1 and 3) classiﬁcation these cases were classiﬁed as RAEB-t (n ¼ 5); M0 P o (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 led information not available; PTD, partial tandem relapse shortly. Only one patient who received BM transplant 19)

achieved long-term survival. The median OS was 9 months ¼ n RAS: 0/12 (3) AML ( (range, 1–96 months). The clinicopathologic features of the 7/11 0.49 (1 and 2) 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.

Molecular studies 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 17)

(Figure 1). Five of the ten MDS patients (50%) were found to ¼ n NA FLT-3 (3/12, 25%); (2) MDS or MDS/MPN( in literature have MLL PTD (Table 1; Figure 1); it is noteworthy that in two 0/4 at MDS 1 at AML transformation 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). (2/10, 20%, at AML transformation) 17) Literature review : 0/5

In total, we identified 17 patients who had MDS or MDS/MPN ¼ n (1) MDS or MDS/MPN ( FLT-3 RAS associated with trisomy 11 reported in the English literature with 2 at AML transformation 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 Comparisons of MDS and AML with trisomy 11 abnormality 2). MLL PTD was performed in ﬁve cases (in Supplementary Table 2, cases 9, 10 and 15–17), and was positive in one case PTD 3/8 (at MDS) that was collected in AML phase. The OS was 11.5 months Table 2 duplication. Overall survival (months), median (range)Abbreviations: AML, acute myeloid leukemia; MDS, myelodysplastic syndromes; MDS/MPN, 14.0 myelodysplastic/myeloproliferative (1–60) neoplasm; NA, detai 11.5 (2–71) 9 (1–96) 0.45 (1 and 2) Other mutations Age (years), median (range)Sex (male/female)Bone marrow cellularity (%),Bone median marrow (range) blasts (%), median (range) 60 (20–95) 9.5 (0–17) 75 (47–85) 13/4 NA NA 69 (52–86) 7/5 80 (10–95) 69 (33–89) 61 (19–93) 0.21 (1 and 3) 0.20 (1 and 2 combined versus 3) 12/7 0.76 (1 and 2 combined versus 3) (range, 2–71). AML transformation, number (%AML of transformation patients) interval (months)MLL 11/16 (69) 5 (1–36) 12/16 (75%) 7 (2–18) NA NA 1.00 (1 and 2) 0.48 (1 and 2)

Leukemia 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 Figure 2 Overall survival (OS) comparison of 31 patients (17 from with intermediate-risk cytogenetic abnormalities (14 versus 28 our series, 14 from literature) with trisomy 11 and myelodysplastic syndromes (MDS) or myelodysplastic/myeloproliferative neoplasm months) (Kaplan–Meier, log-rank P ¼ 0.0002), and comparable (MDS/MPN) with our historical data comprising 1165 MDS MPN to MDS patients with poor-risk cytogenetic abnormalities (14 patients. The median OS of MDS and MPN patients was 14 months, versus 10 months, P ¼ 0.97) (Figure 2). 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 Discussion comparable to MDS patients with poor-risk cytogenetics (n ¼ 230, median OS 10 months, P ¼ 0.97). 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 persistent in the AML phase, and was found in a high number of noncomplex karyotype. These patients were selected from three metaphases by conventional karyotyping. Lastly, four cases in large medical centers over the past 15 years. All these cases our series had low-grade MDS with no trisomy 11 abnormality showed aggressive features including increased blasts at and trisomy 11 was detected at time of progression to RAEB. presentation, a strikingly high frequency of transformation to We have searched the English literature for similar patients AML within a short interval and a short OS. We showed that who had MDS associated with trisomy 11 as a sole abnormality MDS with trisomy 11 shared many features with AML with or as part of a noncomplex karyotype, and we identified 17 trisomy 11, and harbored similar frequency of MLL PTD. patients reported from 12 institutions. These cases showed The frequency and clinical significance of trisomy 11 as a sole strikingly similar aggressive clinicopathologic features to that abnormality or as part of a noncomplex karyotype in MDS had observed in our series as increased BM blasts at the time of not been specified, even in the recently reported large-series presentation, a high frequency of subsequently developing AML studies with focus on the miscellaneous cytogenetic alterations and a short survival. We also compared these patients with our in MDS.14,20,21 The results of our study showed an overall historical MDS database of 1165 MDS patients. Trisomy 11 in frequency of approximately 0.3% in MDS, and most cases were MDS predicts a clearly shorter OS than that of patients with of primary MDS. The clinicopathologic features we observed other cytogenetic alterations in the intermediate-risk cytogenetic indicate that trisomy 11 is important in leukemogenesis or category, and more akin to patients with poor-risk cytogenetics. disease progression. This is evident for a number of reasons. We also compared these MDS patients with their AML First, there was no association with del(7q) or -7, or other counterparts. Similar to those reported by others,1,2,6 AML with balanced translocations such as t(15;17), t(8;21), inv(16), inv(3), trisomy 11 in our series showed frequent morphologic dysplasia, commonly seen in high-grade MDS or AML. Instead, associa- frequent preexisting MDS/cytopenias and low blast number in tions with other trisomies, or other cytogenetic abnormalities the range of 20–30%, features overlapping with MDS associated commonly related to low-grade MDS, such as þ 8, del(5q), with trisomy 11. In addition, we showed that patients with AML were relatively common, mostly present as cytogenetically and trisomy 11 were either resistant to conventional induction related clones. Second, most cases presented with increased BM chemotherapy or experienced rapid disease relapse, and had a blasts in the range of RAEB, and in a strikingly short interval, very short OS. transformed to AML. Third, there were no additional cytogenetic These observations led us to question whether the MDS abnormalities required for AML evolution. Trisomy 11 was 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 Acknowledgements neoplasm harbors certain molecular alterations that could explain their clinical aggressiveness. AML with trisomy 11 has We thank Dr Hwei-Fang Tien and her assistant Shau-Chi at the been shown to have a high frequency of MLL PTD22–24 and National Taiwan University Hospital, Taipei, Taiwan for the interestingly, this MLL PTD likely occurs in the extra copy of technical support in MLL PTD study using genomic DNA PCR. chromosome 11.25 Although the hypothesis that MLL PTD is leukemogenic has References been challenged by its ubiquitous existence in healthy 26 individuals and their life-long persistence, recent observations 1 Slovak ML, Traweek ST, Willman CL, Head DR, Kopecky KJ, and animal models have shown that MLL PTD disturbs normal Magenis RE et al. 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Partial tandem duplication of ALL1 as a recurrent dosage effects of a particular gene, or the entire set of genes on molecular defect in acute myeloid leukemia with trisomy 11. these chromosomes on myeloid cells from particular stages of Cancer Res 1996; 56: 1418–1425. differentiation, as well as alterations in transcript levels of 4 Bernard OA, Romana SP, Schichman SA, Mauchauffe M, Jonveaux mitotic spindle kinases. In our study group we detected P, Berger R. Partial duplication of HRX in acute leukemia with trisomy 11. Leukemia 1995; 9: 1487–1490. MLL PTD within exons 2–6 region in half of MDS cases, 5 Schichman SA, Caligiuri MA, Gu Y, Strout MP, Canaani E, although in two of the cases the samples were collected in AML Bloomfield CD et al. ALL-1 partial duplication in acute leukemia. phase. Rege-Cambrin et al.6 detected MLL PTD in 7 of 13 (54%) Proc Natl Acad Sci USA 1994; 91: 6236–6239. cases of AML with trisomy 11, but not in 3 MDS cases using 6 Rege-Cambrin G, Giugliano E, Michaux L, Stul M, Scaravaglio P, reverse transcription–PCR and Southern blot analyses. Yama- Serra A et al. Trisomy 11 in myeloid malignancies is associated moto et al.12 detected MLL PTD in a case of AML derived with internal tandem duplication of both MLL and FLT3 genes. Haematologica 2005; 90: 262–264. from MDS. In a recent study reported, MLL PTD was found in 7 Collado R, Badia L, Garcia S, Sanchez H, Prieto F, Carbonell F. 8 of 163 (5%) of RAEB cases, and 2 of 210 (1%) low-grade Chromosome 11 abnormalities in myelodysplastic syndromes. MDS cases; however, the karyotype information of these Cancer Genet Cytogenet 1999; 114: 58–61. cases was not revealed.31 It is important to recognize that MLL 8 Gangji D, Noseda A, Wybran J, Verhest A. 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