Correspondence 491 treatment was first relapse after conventional chemotherapy P Moreau Hematology Department, in seven, first relapse after autologous stem cell transplan- A Huynh University Hospital Nantes, tation in 16, stable disease after conventional chemotherapy T Facon Nantes, in five, stable disease after autologous stem cell transplan- I Bouilly France tation in four, and previously untreated MM in three patients. JJ Sotto The median number of lines of therapy before clarithromycin L Legros treatment was two (0–3). Response was evaluated using the N Milpied Myeloma Task Force criteria of 50% reduction in M-band M Attal concentration.3 R Bataille From December 1997 to April 1998, patients received a JL Harousseau for the Intergroupe continuous course of 500 to 1000 mg clarithromycin (median Franc¸ais du Mye´lome (IFM) dose 500 mg twice a day), and neither chemotherapy nor ster- oids were added during antibiotic treatment. Clarithromycin was well tolerated in 69% of cases, but 31% of patients (11/35 patients) experienced gastric pain, anorexia, nausea or References diarrhea. After a median time of 8 weeks (range 4–20), no patient responded to clarithromycin therapy, and MM 1 Bataille R, Harousseau JL. . New Engl J Med progressed in 80% of cases, requiring other therapeutic 1997; 336: 1657–1664. approaches. 2 Durie BGM, Villarete L, Farvard A, Ornopia M, Urnovitz HB. Clar- We conclude that clarithromycin antibiotic treatment has ithromycin as primary treatment for myeloma. Blood 1997; 90 (Suppl. 1): 579a. no efficacy in patients with MM. The difference observed 3 Chronic -Myeloma Task Force. Proposed guide-lines for between our data and the results of Durie et al might be due protocol studies. II. Plasma cell myeloma. Cancer Chemother Rep to the addition of steroids to clarithromycin treatment. 1973; 4: 145–158.

Trisomy 8 as a secondary genetic change in acute megakaryoblastic leukemia associated with Down’s syndrome

TO THE EDITOR feature was observed. The blast cells were cytochemically inert but surface marker analysis revealed positivity for plate- Children with Down’s syndrome (DS) have an approximately let-associated antigens CD41 and CD42b in addition to CD33 10–20-fold increased incidence of acute leukemia.1 There is (myeloid marker), glycophorin-A (erythroid marker) and CD7 an increased incidence of both acute lymphoblastic leukemia (T cell marker which is also aberrantly expressed in AML). A and acute myeloid leukemia (AML), in particular acute diagnosis of AMKL associated with DS was made. Cytogenetic megakaryoblastic leukemia (AMKL). Neonates with DS are study on bone marrow cells showed the following : also at risk of developing a syndrome mimicking acute leuke- 48,XX,+8,+21 [2]/47,XX,+21[10]. Molecular analysis by mia that resolves spontaneously, termed transient abnormal reverse-transcription polymerase chain reaction showed posi- myelopoiesis (TAM), in which blast cells show evidence of tivity for Wilm’s tumour gene () transcript, which has megakaryoblastic differentiation.2 We present a case of AMKL recently been shown to occur in the majority of human acute associated with DS which showed a clonal karyotypic abnor- .3 The patient was treated with the United Kingdom mality of 8(+8) in addition to constitutional trisomy AML XII protocol with mitozantrone. Unfortunately she died 21 (+21). Fluorescence in situ hybridization (FISH) with a cen- of fulminant pneumonia during induction chemotherapy. tromeric probe on bone marrow cells was per- FISH was performed on bone marrow cells using a directly formed in an attempt to delineate lineage involvement in labeled chromosome 8 centromeric probe (Vysis, Downers AMKL associated with DS. Grove, IL, USA) according to protocol of the manufacturer. A 19-month-old baby girl with DS presented with easy The image was captured and analyzed by a Leica Q550CW bruising. There was no known history of TAM in the neonatal Cytogenetics Workstation (Leica Imaging System, Cambridge, period. Physical examination showed no organomegaly or UK), and signals were analyzed in 300 cells. The slide was lymphadenopathy. The complete blood counts showed: hem- then stained with Wright–Giemsa and cells were relocated for oglobin 9.9 g/dl, white cell count 5.2 × 109/l (blasts 12%), and morphological correlation with FISH signals. Trisomy 8 was platelet count 22 × 109/l. A bone marrow aspirate showed confined to the blast population and was not detected in increased blasts (25%) with undifferentiated morphology. myeloid cells, erythroblasts and lymphocytes that were ana- Megakaryocytes were reduced, but both erythropoiesis and lyzed (Figure 1). Out of 75 blast cells analyzed, 45 (61%) granulopoiesis were preserved. No definite myelodysplastic showed three hybridization signals and thus harbored +8 (Figure 1). The false positive and negative rate on a control slide run in parallel were 0% and 2%, respectively. Correspondence: SK Ma, Hematology Section, Dept of Pathology, + University Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong While 8 has previously been recognized as a clonal kary- 2 Kong; Fax: 852 2817 7565 otypic abnormality in acute leukemia associated with DS, its Received 2 September 1998; accepted 13 November 1998 role in leukemogenesis remains to be defined. In our patient Correspondence 492 later on in life, usually within 3 years.1 Conversely, DS with AMKL will, with rare exceptions including our case, give a history of TAM in the neonatal period.6 Taken together, these observations suggest that accumulation of genetic events in addition to +21 may be responsible for subsequent relapse of TAM. The fact that karyotypic abnormalities7 besides +21 are much more frequently encountered in AMKL than in TAM are consistent with this hypothesis. The present study shows that one such cytogenetic change, namely +8, occurs only as a secondary/evolutionary event in the leukemogenic process and that important primary genetic events related to develop- ment of AMKL in DS remains to be established.

SK Ma11Hematology Section, Department of ACW Lee2 Pathology, The University of Hong TSK Wan1 Kong, Queen Mary Hospital; and CK Lam12Department of Pediatrics, Tuen Mun LC Chan1 Hospital, Hong Kong, People’s Republic of China

Figure 1 (A) Bone marrow smear showing three blast cells, a pro- myelocyte, two segmented forms, an erythroblast (arrowhead) and a lymphocyte (double arrowheads). Wright–Giemsa ×1000. (B) FISH References results using a centromeric chromosome 8 probe, showing two blast cells with three signals and a blast cell with two signals (arrow in 1 Avet-Loiseau H, Mechinaud F, Harousseau JL. Clonal hematologic panel A). The promyelocyte, segmented forms, erthroblast and lym- disorders in . A review. J Pediatr Hematol Oncol phocyte all showed two hybridization signals. 1995; 17: 19–24. 2 Hayashi Y, Eguchi M, Sugita K, Nakazawa S, Sato T, Kojima S, Bessho F, Konishi S, Inaba T, Hanada R, Yamamoto K. Cytogenetic with DS and AMKL, +8 was present in a subpopulation of findings and clinical features in acute leukemia and transient mye- blasts only and therefore represents a secondary genetic loproliferative disorder in Down’s syndrome. Blood 1988; 72: + 15–23. change in leukemogenesis. The absence of 8 in other lin- 3 Menssen HD, Renkl H-J, Rodeck U, Maurer J, Notter M, Schwartz eages does not necessarily imply their being normal, since the S, Reinhardt R, Thiel E. Presence of Wilm’s tumor gene (wt1) tran- primary event is not known. In fact, current data from cell scripts and the WT1 nuclear protein in the majority of human culture experiments, blast cell phenotype and gene rearrange- acute leukemias. Leukemia 1995; 9: 1060–1067. ment studies support involvement of an early hemopoietic cell 4 Brodeur GM, Dahl GV, Williams DL, Tipton RE, Kalwinsky DK. capable of multilineage differentiation in AMKL associated Transient leukemoid reaction ant trisomy 21 mosaicism in a 1 phenotypically normal newborn. Blood 1980; 55: 691–693. with DS. 5 Ridgway D, Benda GI, Magenis E, Allen L, Segal GM, Braziel RM, In TAM associated with DS, the abnormal proliferation of Neerhout RC. Transient myeloproliferative disorder of the Down blast cells is linked to the presence of an extra copy of chro- type in the normal newborn. Am J Dis Child 1990; 144: 1117– mosome 21. Support for this contention is provided by cases 1119. of TAM in a phenotypically normal newborn with +21 6 Zipursky A, Brown E, Christensen H, Sutherland R, Doyle J. Leuke- mosaicism4 and in two genetically normal neonates,5 in mia and/or myeloproliferative syndrome in neonates with Down + syndrome. Semin Perinatol 1997; 21: 97–101. whom the abnormal proliferating population also harbors 21. 7 Ma SK, Ha SY, Wan TSK, Chan LC. Translocation (5;7)(q34;q21) Although the clinical course of TAM is that of spontaneous in acute megakaryoblastic leukemia associated with Down syn- resolution, around 25% of such patients will relapse as AMKL drome. Cancer Genet Cytogenet 1997; 96: 177.