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A Case of Mixed T Lymphoblastic and Myeloblastic Leukaemia

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A Case of Mixed T Lymphoblastic and Myeloblastic Leukaemia J Clin Pathol: first published as 10.1136/jcp.38.5.575 on 1 May 1985. Downloaded from J Clin Pathol 1985;38:575-581 Biphenotypic leukaemia: a case of mixed T lymphoblastic and myeloblastic leukaemia MAM MORGAN, CS SCOTT, J TAVARES DE CASTRO,* HJ LIMBERT, N POLLI,* D CATOVSKY,* RD PYRAH,t BE ROBERTS From the Department ofHaematology, Regional Radiotherapy Centre, Cookridge Hospital, Leeds, the *MRC Leukaemia Unit, Royal Postgraduate Medical School, London, and tAiredale General Hospital, Keighley, W Yorkshire SUMMARY A case of mixed acute leukaemia with T lymphoblastic, myeloblastic, and monocytic components is described. The use of immunological markers, ultrastructural morphology, cytochemistry, immunochemistry, and combined techniques, simultaneously detecting two mar- kers in individual cells, made it possible to define the different blast cell populations. Neoplastic disorders are believed to arise from the showed haemoglobin 6*0 g/dl, white cell count 167 uncontrolled clonal proliferation of a single pro- x 109/l (differential 98% blasts, 2% lymphocytes, genitor cell. With the use of monoclonal antibody with an occasional granulocyte) and platelet count techniques, an increasing number of leukaemias and 65 x 1O9/l. The biochemical profile was normal and 3 lymphomas' are found to have a mixed Escherichia coli was isolated from a urine culture. A copyright. phenotype. A biphenotypic leukaemia is one in bone marrow aspirate was hypercellular with sheets which leukaemic cell populations with apparent of blasts, the morphological and immunological fea- myeloid and lymphoid characteristics coexist. This is tures of which are described below. in contrast to leukaemias of hybrid phenotype, in She received induction chemotherapy with which leukaemic cells show phenotypic features of daunorubicin, vincristine, and prednisolone and a more than one cell line, suggesting the existence of bone marrow aspirate performed eight weeks later lineage infidelity.4 This report describes a case of indicated complete remission. Maintenance http://jcp.bmj.com/ mixed leukaemia characterised by two distinct popu- chemotherapy was started comprising methotrexate, lations of blasts: one showed the features of acute T 6-mercaptopurine, cytosine arabinoside, vincristine, lymphoblastic leukaemia, the other acute myelo- and prednisolone. The patient remains in first remis- blastic leukaemia with some monocytic differentia- sion on maintenance chemotherapy 16 months after tion. The biphenotypic nature of this leukaemia was presentation. established by light microscopy, morphology and cytochemistry, monoclonal antibody studies, and MATERIAL AND METHODS on September 26, 2021 by guest. Protected electron microscopy. Light microscopy, morphology, and cytochemistry The morphology of the peripheral blood and bone Case report marrow was examined on May-Grunwald-Giemsa stained smears. Cytochemical staining of blood and A 65 year old woman presented with an acute bone marrow for myeloperoxidase, Sudan black, leukaemia. She had a history of general malaise, chloroacetate esterase, a-naphthyl acetate esterase, recurrent infections, mouth ulcers, easy bruising, periodic acid Schiff, and acid phosphatase were per- and weight loss. The salient clinical features were: formed by standard techniques. fever 38°C, anaemia, bruising on the limbs, 2 cm x 1 cm tender inguinal node, palpable spleen tip, and Immunological phenotyping 6 cm hepatomegaly. There was no mediastinal Peripheral blood whole leucocyte and mononuclear mass on a chest radiograph. A full blood count cell fractions were separated by Plasmagel induced red blood cell rouleaux formation and Lymphoprep density gradient centrifugation respectively. Both fractions comprised in excess of 98% blasts. Accepted for publication 18 January 1985 Immunological phenotyping was performed by (a) 575 J Clin Pathol: first published as 10.1136/jcp.38.5.575 on 1 May 1985. Downloaded from 576 Morgan, Scott, De Castro, Limbert, Polli, Catovsky, Pyrah, Roberts detection of cell surface antigens by indirect simultaneously with cytoplasmic myeloperoxidase immunofluorescence of living cell suspensions using was achieved as previously described.6 The mono- a panel of monoclonal antibodies (specificities, clonal antibodies used in these combination techni- sources, and references listed in Table 1); (b) ques were. antigranulocyte FMC13;7 8 antimonocyte demonstration of terminal deoxynucleotidyl trans- FMC17 and FMC32,69 OKMI;'0 anti-T cell 3AI;" ferase (TdT) with a rabbit anticalf TdT serum by and an anti-HLADr equivalent, FMC4.'2 indirect immunofluorescence of methanol fixed cytocentrifuge preparations5; and (c) E rosetting RESULTS with sheep red blood cells. Light microscopy To assess the expression of two markers in the Examination of May-Grunwald-Giemsa stained same cell, combinations of TdT with E rosettes, 3AI, blood and bone marrow smears showed two popula- and My9 were performed as follows: (a) E rosette tions of blasts. About 70% of these were typical preparations were cytocentrifuged, fixed, and pro- lymphoblasts with a high nuclear to cytoplasmic cessed for TdT as above; (b) 3Al and My9 were ratio and convoluted nucleus, while the remainder detected in cell suspension using a fluorescein con- showed the features of myeloblasts, with a lower jugated secondary antibody, cytocentrifuged cell nuclear to cytoplasmic ratio, a single nucleolus, and monolayers prepared, and TdT examined using a occasional granules in the cytoplasm. Cytochemi- rhodamine conjugated secondary antibody. Nega- cally, 60% of blasts showed weak to moderate focal tive controls were obtained by omitting the primary acid phosphatase activity, 10% of blasts showed antibody or by using an irrelevant antibody. weak myeloperoxidase and Sudan black reactivity, and there was no significant chloroacetate esterase, Electron microscopy a-naphthyl acetate esterase, or periodic acid Schiff Cells were processed for ultrastructural morphology activity. These preliminary results indicated two and detection of myeloperoxidase at electron mic- populations of blasts: a minor proportion showing roscopy level using conventional techniques.6 The myeloid differentiation with the remainder having sugges- demonstration of cell surface antigens by mono- the typical acid phosphatase focal positivity copyright. clonal antibodies and the immunogold method tive of T cell acute lymphoblastic leukaemia blasts. Table 1 Immunological phenotype ofthe blast cells Marker % Positive cells* Specificity Source Reference http://jcp.bmj.com/ Precursor cells TdT 69 Terminal transferase PL/Pharmacia 5 FMC4 60 HLA-Dr Sera Lab 12 12 40 HLA-Dr Coulter 28 J5 <1 Common acute lymphoblastic leukaemia Coulter 29 antigen T cells OKT17 50 T cells Dr G Goldstein 30 3A1 30 T cells Prof B Haynes 11 OKT11 25 red blood cell Ortho 13 Sheep receptor on September 26, 2021 by guest. Protected E-rosettes 22 Sheep red blood cell receptor UCHT1 5 T cells (T3 equivalent) Dr P Beverley 31 OKT4 <1 Helper T cells Ortho 13 OKT8 <1 Suppressor T cells Ortho 13 OKT6 <1 Cortical thymocytes Ortho 13 HTA-1 (NA1/34) <1 Cortical thymocytes Sera Lab 32 Myeloid cells My7 14 Granulocytes, monocytes, and precursors Coulter 33 My9 13 Early granulocytes, monocytes, and Coulter 34 precursors FMC17 14 Predominantly monocytes/macrophages Dr H Zola 9 FMC32 7 Predominantly monocytes/macrophages Dr H Zola 9 LeuM3 10 Predominantly monocytes/macrophages Becton-Dickinson 35 My4 11 Predominantly monocytes/macrophages Coulter 33 UCHM1 9 Predominantly monocytes/macrophages Dr P Beverley 36 61D3 <1 Predominantly monocytes/macrophages BRL 35 Mo2 <1 Predominantly monocytes/macrophages Coulter 37 Other lineages LICR/LON/R10 <1 Glycophorin A, erythroid cells Dr P Edwards 38 AN51 <1 Platelet glycoprotein lb Prof A McMichael 39 B1 <1 B cells Coulter 40 *Blasts comprised in excess of 98% of the leucocyte fraction tested. J Clin Pathol: first published as 10.1136/jcp.38.5.575 on 1 May 1985. Downloaded from Biphenotypic leukaemia: a case of mixed T lymphoblastic and myeloblastic leukaemia 577 i-W i i ,-. I I i i Fig. 1 Lymphoblast. Note the high nuclear to cytoplasmic ratio, the inconspicuous nucleolus, and two nuclear pockets (arrow). Uranyl acetate and lead citrate staining. Original magnification x 18500. copyright. http://jcp.bmj.com/ ?gaP .,St. .E*. Jg .§!:.: *.. ^A ...,:4t ..N ::XjlBy .. .; :.:::: :. .: : , .a.: .: :. .E- Fig. 2 Myeloblast, ...... Ss N;. myeloperoxidase reaction. Note the on September 26, 2021 by guest. Protected ct...@,'t,x2, 9 presence ofmyeloperoxidase activity in the perinuclear space *: ..s.* *.s.. (small arrow), rough endoplasmic .. b . reticulum, Golgi apparatus I * 2' ?; , t l,:. (asterisk), and small and medium .. sized granules. This pattern ^ ¼. :: ... .>:e:. a indicates active synthesis ofthe enzyme in an immature cell. A .X nuclear .. pocket (large arrow) encloses an area ofcytoplasm containing myeloperoxidase .. :., . .. ':! '' s ,, I material. 4, reactive Original .* s.,:. .. *Ws .. 0 .......Rh. magnification x 14 700. .: i..1:1.f.. .:.:, k:.::: ::, sx:::I:t.: 6. .. : _ i, 6.., 10, -1 aF-l OF ~~4XOM J Clin Pathol: first published as 10.1136/jcp.38.5.575 on 1 May 1985. Downloaded from 578 Morgan, Scott, De Castro, Limbert, Polli, Catovsky, Pyrah, Roberts \A n Ak. .r .s .ilf iai. Fig. 3 Monocytoid cell, ,Bi combined detection ofa monocytic *_s *gg antigen (FMC32) and myeloperoxidase. The small myeloperoxidase containing granules and the villous cytoplasmic outline are characteristic ofthe monocytic lineage. The 30 nm
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