Case #1. 65 yo man with no prior history presented with leukocytosis and circulating blasts: Bone marrow biopsy was performed
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1 Case #1 65 yo man with no prior history presented with leukocytosis and circulating blasts: WBC 187.4K/uL ; Hgb 10.0gm/dL; Platelet 68K/uL Neutrophil % 25.0% Lymphocyte % 38.0% Monocyte % 12.0% Metamyelocyte 10.0% Blasts 15.0% Bone marrow biopsy was performed
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![2)[20] FISH: BCR-ABL1 fusion signal](/docs-images/95/123531257/images/3-1.jpg "in 97% of the interphases")
3 PB MPO BM Cytogenetics: 46,XY,t(9;22)(q34;q11.2)[20] FISH: BCR-ABL1 fusion signal in 97% of the interphases Molecular: b2a2 coding for p210 Flow Cytometry: CD19+/CD22+/CD79a+/CD34+ 42% blasts What is the diagnosis?
4 Case #2 67 yo woman with no prior history presented with leukocytosis and circulating blasts: WBC 18.0K/uL; Hgb 9.3gm/dL; Platelet 151K/uL Neutrophil % 50.0% Lymphocyte % 12.0% Monocyte % 2.0% Basophil 7.0% Metamyelocyte 1.0% Blasts 28.0% Bone marrow biopsy was performed
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6 PB Cytogenetics: 46,XX,t(9;22)(q34;q11.2)[17]/47,idem,+8[3] FISH: BCR-ABL1 fusion signal in 95% of the interphases Molecular: 1. co-expression of b3a2 and b2a2 coding for p Mutations in NPM1, RUNX1 and WT1 BM Flow Cytometry: Myeloblasts positive for MPO (partial), negative for T and B markers 25% blasts What is the diagnosis?
7 Question: How to differentiate between: De novo Acute leukemia with BCR-ABL1 and CML with blast phase as the initial presentation
8 AML with BCR-ABL1 versus CML blast phase From WHO: Features favor AML with BCR-ABL1 : 1. AML-associated mutations, in particular NPM1 and FLT3-IDH, restricted to AML with BCR-ABL. 2. Loss of IKZF1 and CDKN2A as well as cryptic deletions within the IGH and TRG genes only seen in AML with BCR-ABL. 3. Less splenomegaly, less dwarf megakaryocytes and lower peripheral blood basophilia (usually <2%) Our experience: 1. FISH is the most reliable way to differentiate them: the presence of BCR-ABL1 fusion signal in mature cells supports CML blast phase. 2. The emergence of chronic phase after induction therapy supports CML blast phase. 3. In addition, the presence of basophilia, eosinophilia, splenomegaly and other MPN features favor CML blast phase. 4. NPM1 mutation is not reliable to differentiate them.
9 PB Go back to Case #1: Diagnosis: Lymphoblastic phase of CML, not B-ALL with BCR-ABL BM Cytogenetics: 46,XY,t(9;22)(q34;q11.2)[20] FISH: BCR-ABL1 fusion signal in 97% of the interphases Molecular: b2a2 coding for p210 Flow Cytometry: CD19+/CD22+/CD70a+/CD34+ 42% blasts
10 Case #1 FISH BCR-ABL1 fusion signal in 97% of the interphases, including some mature cells BCR-green, ABL-red
11 Go back to Case #2 Diagnosis: Myeloblastic phase of CML, not AML with BCR-ABL Cytogenetics: 46,XX,t(9;22)(q34;q11.2)[17]/47,idem,+8[3] FISH: BCR-ABL1 fusion signal in 95% of the interphases Molecular: 1. co-expression of b3a2 and b2a2 coding for p Mutations in NPM1, RUNX1 and WT1 Flow Cytometry: Myeloblasts positive for MPO (partial), negative for T and B markers
12 Case #2 FISH BCR-ABL1 fusion signal in 95% of the interphases
13 An improved way to perform FISH: correlate with morphology (dual color, break-apart probe)
14 Case #3: In cases with very high blast counts, it is difficult to assess whether BCR-ABL1 is present in mature cells, pay attention to follow-up bone marrow! 59 yo woman with no prior history presented with leukocytosis and circulating blasts: WBC 26.3K/uL ; Hgb 8.2gm/dL ; Platelet 40K/uL Neutrophil % 16.0% Lymphocyte % 6.0% Monocyte % 2.0% Basophil 1.0% Eosinophil 2.0% Metamyelocyte 1.0% Blasts 73.0%
15 Cytogenetics: 46,XX,t(9;22)(q34;q11.2)[20] FISH: BCR-ABL1 fusion signal in 90% of the interphases Molecular: 1. b2a2 coding for p210. Flow Cytometry: B-ALL 1 month after R-HCVAD + ponatinib treatment Flow Cytometry: Negative for MRD. Cytogenetics: 46,XX,t(9;22)(q34;q11.2)[3]/46, XX[17] FISH: BCR-ABL1 fusion signal in 12% of the interphases Molecular: 1. b2a2 coding for p210.
16 BCR-ABL1 fusion signal is identified in neutrophils, c/w CML
17 Summary Acute leukemia with BCR-ABL1 versus Blast phase of CML 1. FISH can tell them apart. The presence of BCR-ABL1 fusion signal in mature cells supports blast phase of CML (cases #1 and #2) 2. The emergence of chronic phase after induction therapy supports CML blast phase (case #3) 3. NPM1 mutation is not specific to AML with BCR-ABL1. It can be seen in blast phase of CML
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