Acute Lymphoblastic Leukemia in Elderly Patients The Philadelphia Chromosome May Not Be a Significant Adverse Prognostic Factor

Transcription

1 Hematopathology / ACUTE LYMPHOBLASTIC LEUKEMIA IN ELDERLY PATIENTS Acute Lymphoblastic Leukemia in Elderly Patients The Philadelphia Chromosome May Not Be a Significant Adverse Prognostic Factor Mihaela Onciu, MD, 1* Carlos Bueso-Ramos, MD, PhD, 1 L. Jeffrey Medeiros, MD, 1 Greg Ball, MS, 2 Terry Smith, MS, 2 and Raymond Lai, MD, PhD 1 Key Words: Acute lymphoblastic leukemia; Elderly; Philadelphia chromosome Abstract Acute lymphoblastic leukemia (ALL) in elderly patients (59 years or older) carries a poor prognosis, and this finding may be attributed to the relatively high frequency of the Philadelphia chromosome (Ph). To test this hypothesis, we reviewed the clinicopathologic features of 23 consecutive, newly diagnosed elderly patients with ALL (14 men, 9 women, aged years) uniformly treated at our institution and compared the Ph+ and Ph groups. Conventional cytogenetic data were available for 21 of 23 cases; 7 (33%) were Ph+. All Ph+ cases were of precursor B-cell type. The remaining 16 tumors were of precursor B-cell (10), mature B-cell (2), precursor T-cell (3), and mixed precursor T-cell/B-cell (1) type. Ph+ and Ph groups did not differ significantly in median survival (13.4 months vs 19.0 months) or other variables studied. The Ph may not be a significant adverse prognostic factor in ALL in elderly patients. Acute lymphoblastic leukemia (ALL) in elderly patients, generally regarded as patients at least 59 years old, has been associated with a poor prognosis in several studies using a variety of therapeutic regimens. 1-7 With the advent of doseintensive chemotherapy regimens such as hyper-cvad (fractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone), overall survival has not improved substantially despite a high rate of complete remission This poor clinical outcome has been attributed to various age-associated host factors, including poor organ function and performance status and delayed hematologic recovery after chemotherapy. Factors intrinsic to ALL in elderly patients also may explain the poor prognosis in this age group. In this regard, elderly patients with ALL are known to have a higher frequency of the Philadelphia chromosome (Ph) than do children and young adults. 5,11,12 Only a small number of ALL cases in elderly patients with cytogenetic data have been reported. 1,4 Since the Ph is an adverse prognostic factor in children and young adults with ALL, 11,13-16 it is possible that the poor outcome for elderly patients with ALL is attributed to the relatively high frequency of the Ph. To test this hypothesis, we reviewed the clinicopathologic and conventional cytogenetic findings in 23 consecutive, newly diagnosed elderly patients with ALL who were treated uniformly with the hyper-cvad regimen at our institution. To our knowledge, this series is the largest number of cases of ALL in elderly patients with conventional cytogenetic data reported. Materials and Methods Case Selection The files of the Department of Hematopathology, University of Texas M.D. Anderson Cancer Center, Houston, 716 Am J Clin Pathol 2002;117: American Society for Clinical Pathology

2 Hematopathology / ORIGINAL ARTICLE were searched for elderly patients with ALL treated between July 1994 and May The inclusion criteria for the study were as follows: (1) diagnosis of ALL established on the basis of bone marrow morphologic features, cytochemistry, and immunophenotype; (2) age 59 years or older; (3) de novo acute leukemia with no antecedent hematologic disorders such as chronic myeloid leukemia; and (4) no chemotherapy before arrival at our institution. The patients medical records were further searched for various laboratory and clinical data at the time of initial admission to our institution. The laboratory findings included the bone marrow blast count, CBC count and differential, and serum levels of albumin, total bilirubin, creatinine, lactate dehydrogenase, and alkaline phosphatase. The clinical findings recorded included the results of the physical examination, radiologic findings, history of malignancy, clinical response to induction chemotherapy, and length of survival. Flow Cytometry Immunophenotypic studies were performed on all cases using a flow cytometer (Becton Dickinson, San Jose, CA) as described previously. 17 CD45 expression vs side-scatter was used to analyze the blast population, assessed using a panel of monoclonal antibodies specific for terminal deoxynucleotidyl transferase, HLA-DR, CD1a, CD2, CD3 (cytoplasmic and surface), CD4, CD5, CD7, CD8, CD10, CD13, CD14, CD19, CD20, CD22 (cytoplasmic and surface), CD33, CD64, CD117, surface immunoglobulin M and D heavy chains, and surface immunoglobulin kappa and lambda light chains (Becton Dickinson). Conventional Cytogenetics Conventional cytogenetic analysis was performed on all bone marrow samples as described previously. 17 The method involved 24-hour unstimulated bone marrow cultures, followed by routine harvesting and G-banding. When possible, at least 20 metaphases were analyzed in each case, and the karyotypes were recorded according to the 1995 International System for Human Cytogenetic Nomenclature. Western Blot Analysis of the bcr-abl Protein Western blot analysis using peripheral blood specimens was performed in 6 of 7 Ph+ cases of ALL to identify the specific type (P210 or P190) of bcr-abl protein. The type of bcr-abl transcripts also was assessed by reverse transcriptase polymerase chain (RT-PCR) reaction using bone marrow aspirates in 3 of 7 Ph+ cases. One Ph+ case was assessed only by RT-PCR using bone marrow aspirate material. Details of these techniques have been described previously. 18 Statistical Analysis The frequencies of various clinical and laboratory variables in patients with Ph+ versus Ph ALL were compared using the 2-tailed Fisher exact test. Survival of the Ph+ and Ph groups was plotted by using the Kaplan-Meier method, and the difference between groups was evaluated statistically by using the log-rank test. Results We identified 23 consecutive cases of ALL occurring in patients at least 59 years old. There were 14 men and 9 women, with a median age of 65 years (range, years). All patients were treated uniformly with the hyper-cvad regimen as induction chemotherapy. Conventional cytogenetics studies were performed in all cases; 21 of 23 had analyzable metaphases. The results are summarized in Table 1. The most frequent karyotypic abnormality was the Ph, which was identified in 7 (33%) of 21 cases; 3 cases had the Ph as a sole karyotypic abnormality, and 4 had additional random abnormalities. In 8 cases (38%), karyotypic abnormalities other than the Ph were identified; 2 cases had 1 abnormality, and 6 cases had 3 or more karyotypic abnormalities. Most of these abnormalities were random; the only regions that were involved more than once were 2q3 (cases 15 and 16) and 6q2 (cases 20 and 21). Six (29%) cases were diploid. Of the 2 cases that had no analyzable metaphases, 1 was of precursor T-cell type, which is typically Ph, and the other was of precursor B-cell type, which showed no evidence of Ph by Southern blots. Of the 7 Ph+ cases, 6 were tested by Western blot analysis. P190 protein was detected in 3 cases, and P210 was detected in 3 cases. Three Ph+ cases were tested by RT-PCR; P190 transcripts were found in 2 and P210 transcripts in 1. Overall, the P190 bcr-abl was present in 4 (57%) of 7 cases of ALL and P210 bcr-abl in 3 (43%) of 7 cases of ALL. A comparison of the clinical and pathologic features between the Ph+ and Ph groups was performed, and the results are summarized in Table 2. There were no significant differences in various clinical features examined, including median age, frequency of hepatomegaly, splenomegaly, lymphadenopathy, mediastinal mass, central nervous system involvement, and the following laboratory results: hemoglobin, less than 10 g/dl (<100 g/l; reference range, g/dl [ g/l] for men, g/dl [ ] for women); platelet count, less than /µl (< /L; reference range, /µl [ /L]); WBC count, more than 30,000/µL (> /L; reference range, 4,000-11,000/µL [ /L); peripheral blood blasts, more than 30%; bone marrow blasts, more than 80%; serum levels of lactate dehydrogenase, more than 600 U/L (reference range, U/L); alkaline phosphatase, more than 80 U/L (reference range, U/L); creatinine, more than 1.3 mg/dl (>115 µmol/l; reference range, mg/dl [ µmol/l]); bilirubin, more than American Society for Clinical Pathology Am J Clin Pathol 2002;117:

3 Onciu et al / ACUTE LYMPHOBLASTIC LEUKEMIA IN ELDERLY PATIENTS Table 1 Conventional Cytogenetic Findings in 21 Cases of Acute Lymphoblastic Leukemia in Elderly Patients Case No. Karyotype at Diagnosis 1 46,XX,t(9;22)(q34;q11)[10]/46,XX[10] 2 46,XX,t(9;22)(q34;q11)[14]/46,XX[6] 3 46,XY,t(9;22)(q34;q11)[12]/46,XY[8] 4 45~52,XY,+X,del(1)(p34.1),del(5)(q21;q25), 7, 9,t(9;22)(q34;q11),add(14)(q32),der(22)t(9;22),+21[cp4] 5 46,XX,der(1)ins(1;?)(q42;?)t(1;16)(q42;q24)t(1;22)(q42;11),der(9)t(9;22)(q34;q11),der(16)t(1;16),der(22)t(1;22)t(9;22)[15]/46,XY[4] 6 40~46,XY,add(4)(q35),der(9)del(9)(q22)t(9;22)(q34;q11),+der(22)t(9;22)[3]/46,XY[17] 7 55~58,XY,+2,+4,+6,t(9;22)(q34;q11),+10,+12,+18,+21,+der(22)t(9;22)[6]/46,XY[12] 8 46,XX[29] 9 46,XX[20] 10 46,XY[20] 11 46,XY[20] 12 46,XY[19] 13 46,XX[20] 14 46,XY, 2,+mar[6]/46,XY[14] 15 46,XX,del(2)(q21q31)[6]/46,XX[14] 16 46,XY,del(2)(q31),del(6)(q24),add(15)(q26)[6]/46,XY[14] 17 45~54,XX,+5,+6,+9,+10, 12,+13,del(22)(q11),+mar[3] 18 44~45,XY,del(7)(q22),add(11)(q25),add(13)(q34)[10]/44~45,XY,idem,+1 3mar[cp9] 19 46,XY,+1,t(1;19)(q21;q13.3),der(1;15)(q10;q10),t(5;15)(q33;q15),ins(7;?)(p15;?)[3]/45,X, Y[4]/46,XY[32] 20 46,XY,t(1;3)(p32;q26.2),del(6)(q21),t(8;22)(q24.3;q11),add(14)(q32);t(14;18)(q32;q21),+1 3mar[4]/46,XY[22] 21 44~46,XY,t(1;3)(p36;p13),del(5)(q15),add(6)(q27),del(7)(q22), 17,+3 4mar[7]/46,XY[22] 1.3 mg/dl (22 µmol/l; reference range, <1 mg/dl [<17 µmol/l]); and albumin, less than 3.0 g/dl (30 g/l; reference range, g/dl [35-47 g/l]). These laboratory cutoffs have been used previously by others. 8 Morphologically, 5 were L1, 16 were L2, and 2 were L3 (Burkitt-type) using the French-American-British system. 19 Of the 7 Ph+ cases, 1 was L1 and 6 were L2. Immunophenotypically, all 7 patients with Ph+ ALL had a precursor B-cell immunophenotype and were CD10+. The Ph ALL group was more heterogeneous: 10 (62%) were precursor B cell, 2 (12%) were mature B cell (both L3), 3 (19%) were precursor T cell, and 1 (6%) was of mixed precursor T- and B-cell lineage. There was no significant difference in the frequency of myeloid antigen expression in the Ph+ and Ph cases of ALL. Complete clinical remission was achieved in 5 (71%) of 7 patients with Ph+ ALL and 15 (94%) of 16 patients with Ph ALL. The median survival for all 23 patients was 16.2 months. The median survival periods for patients in the Ph+ and Ph groups were 13.4 and 19.0 months, respectively. The overall survival between these groups was not significantly different (P =.24, log-rank test) Figure 1. The median survival periods for patients with Ph+ precursor B- cell type (n = 7) and those with Ph precursor B-cell type (n = 10) were also 13.4 and 19.0 months, respectively. This difference was not statistically significant. Discussion Various clinical and pathologic parameters have been used to stratify patients with ALL into different prognostic groups. In a multicenter prospective study involving 368 uniformly treated adult patients, Hoelzer et al 20 showed by multivariate analysis that the most important factors of poor prognosis in ALL include patient age older than 35 years, WBC count of more than 30,000/µL (> /L), null immunophenotype, and more than 4 weeks required to achieve remission. Kantarjian et al, 11 in their single-center study of 268 adults uniformly treated with the vincristine- Adriamycin [doxorubicin]-dexamethasone regimen, emphasized the importance of additional prognostic factors that have an impact in elderly patients (defined as 60 years or older in that study). They proposed a 3-tier prognostic group system based on a regression model incorporating performance status, WBC count, serum albumin level, serum creatinine level, and conventional cytogenetics results. Their findings underscore the fact that in the elderly, performance status and organ function have a more significant bearing on therapy outcome than in younger patients. The advent of dose-intensive chemotherapy, such as hyper-cvad, has modified to some extent the relative importance of the various prognostic factors. Kantarjian et al 8 described 204 adult patients uniformly treated in a single center with the hyper- CVAD regimen. In that study, while most of the previously delineated prognostic factors retained their importance, others, including a WBC count of more than 30,000/µL ( /L) showed only a trend toward statistical significance. Multiple studies have shown a significant association between certain cytogenetic abnormalities and prognosis in patients with ALL. Adverse cytogenetic markers include the Ph, 11q23 abnormalities, t(1;19), and 8q24 abnormalities. 8,12-16,21 The clinical significance of some of these prognostic factors 718 Am J Clin Pathol 2002;117: American Society for Clinical Pathology

4 Hematopathology / ORIGINAL ARTICLE Table 2 Characteristics of 23 Elderly Patients With Philadelphia Chromosome (Ph)-Positive vs Ph-Negative Acute Lymphoblastic Leukemia * Variable Positive (n = 7) Negative (n = 16) P Age range (y) (median, 66) (median, 65.5) Splenomegaly 1 (14) 4 (25) 0.65 Hepatomegaly 1 (14) 2 (12) 1.0 Lymphadenopathy 2 (29) 3 (19) 1.0 Mediastinal mass 0 (0) 1 (6) 1.0 Central nervous system involvement 0 (0) 0 (0) 1.0 Hemoglobin, <10 g/dl (<100 g/l) 4 (57) 9 (56) 1.0 WBC count, >30,000/µL (> /L) 2 (29) 1 (6) 0.20 Platelet count, < /µl (< /L) 4 (57) 13 (81) 0.31 Peripheral blasts, >30% 4 (57) 9 (56) 1.0 Marrow blasts, >80% 6 (86) 10 (62.5) 0.36 Creatinine, >1.3 mg/dl (>115 µmol/l) 2 (29) 3 (19) 1.0 Bilirubin, >1.3 mg/dl (>22 µmol/l) 0 (0) 1 (6) 1.0 Albumin, <3.0 g/dl (<30 g/l) 0 (0) 4 (25) 0.27 Serum alkaline phosphatase, >80 U/L 5 (71) 12 (75) 1.0 Serum lactate dehydrogenase >600 U/L 5 (71) 13 (81) 1.0 Immunophenotype Precursor B-cell (CALLA) 7 (100) 10 (62) Mature B-cell 0 (0) 2 (12) 0.55 Precursor T-cell 0 (0) 3 (19) 0.52 Mixed B-cell and T-cell lineage 0 (0) 1 (6) 1.0 Myeloid markers present 3 (43) 8 (50) 1.0 Myeloid markers in precursor B-cell 3 (43) 4 (40) 1.0 Karyotype Diploid 0 (0) 6 (38) 0.12 Pseudodiploid 4 (57) 3 (19) chromosomes 1 (14) 0 (0) 0.30 >50 chromosomes 1 (14) 0 (0) 0.30 <46 chromosomes 1 (14) 2 (12) q23 abnormalities 0 (0) 1 (6) 1.0 8q24 abnormalities 0 (0) 1 (6) 1.0 t(1;19)(q23;p13) 0 (0) 1 (6) 1.0 No analyzable metaphases 0 (0) 2 (12) CALLA, common acute lymphoblastic leukemia antigen. * Data are given as number (percentage) unless otherwise indicated. Fisher exact test, 2-tailed. n = 10. Survival Follow-up Time (Months) Figure 1 Acute lymphoblastic leukemia (ALL) in 23 elderly patients. There was no significant difference in overall survival between patients with Philadelphia chromosome positive (dotted line) and Philadelphia chromosome negative (solid line) ALL (P =.24, log-rank test, Kaplan-Meier method). varies with the age of patients. For instance, cytogenetic abnormalities that have a strong prognostic impact in childhood ALL, such as DNA ploidy, are not as important in adults with ALL. 12 Similarly, we found that the clinical significance of the Ph may be age-dependent and that the Ph does not seem to be a significant adverse prognostic factor in elderly patients, in contrast with pediatric and young adult patients. 14,15 The exact mechanisms underlying the prognostic significance of the Ph in ALL of children and young adults are unknown. There is also no clear explanation for the apparent lack of prognostic significance of the Ph in elderly patients. One possibility is that the new and effective hyper-cvad regimen may have muted the adverse prognostic effects of the Ph in this setting. However, we believe that this is not likely, since the presence of the Ph is an adverse prognostic factor in adults of all ages treated with hyper-cvad at our institution. 8 In an abstract from a recent report written in Japanese, Nagura et al 22 reported that the Ph is not a significant prognostic factor in ALL in elderly patients, and their study involved patients American Society for Clinical Pathology Am J Clin Pathol 2002;117:

5 Onciu et al / ACUTE LYMPHOBLASTIC LEUKEMIA IN ELDERLY PATIENTS treated with at least 4 different chemotherapy regimens. Thus, it is more likely that the lack of prognostic importance of the Ph in ALL in elderly patients is specific to this age group rather than related to the effectiveness of chemotherapy. Despite the fact that the presence of the Ph does not contribute significantly to the poor prognosis of ALL in elderly patients, it remains possible that Ph+ ALL may be biologically different from Ph ALL in this age group. To support this concept, we found that the immunophenotype of Ph+ ALL was uniformly precursor B cell, whereas the immunophenotype of the Ph ALL group was more heterogeneous. The relatively small number of patients included in this study limits statistical analysis. Nevertheless, ALL in elderly patients is a rare entity, and few studies addressing this entity reported previously have included patient numbers of comparable size. Of note, all patients in this study were uniformly treated at a single institution with the hyper- CVAD regimen, which has been shown to confer a better response rate compared with other treatment regimens used in adults with ALL. 8 In contrast, most studies reported previously have included patients treated with several different chemotherapy regimens Despite the high rate of complete remission induced by hyper-cvad, ALL in elderly patients has a poor overall prognosis. The clinical significance of the Ph is age-dependent, and the Ph does not seem to be a significant adverse prognostic factor in ALL in elderly patients. The overall poor prognosis in ALL in this age group probably is related to other intrinsic aspects of the tumor or host factors. From the Departments of 1 Hematopathology and 2 Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston. Address reprint requests to Dr Lai: Dept of Hematopathology, Box 72, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, * Dr Onciu is now with the Department of Pathology, St Jude Children s Research Hospital, Memphis, TN. References 1. Delannoy A, Ferrant A, Bosly A, et al. Acute lymphoblastic leukemia in the elderly. Eur J Haematol. 1990;45: Ferrari A, Annino L, Crescenzi S, et al. Acute lymphoblastic leukemia in the elderly: results of two different treatment approaches in 49 patients during a 25-year period. Leukemia. 1995;9: Preti HA, O Brien S, Giralt S, et al. Philadelphiachromosome positive adult acute lymphocytic leukemia: characteristics, treatment results, and prognosis in 41 patients. Am J Med. 1994;97: Taylor PRA, Reid MM, Proctor SJ. Acute lymphoblastic leukemia in the elderly. Leuk Lymphoma. 1994;13: Taylor PRA, Reid MM, Bown N, et al. Acute lymphoblastic leukemia in patients aged 60 years and over: a population-based study of incidence and outcome. Blood. 1992;80: Späth-Schwalbe E, Heil G, Heimpel H. Acute lymphoblastic leukemia in patients over 59 years of age: experience in a single center over a 10-year period. Ann Hematol. 1994;69: Virgilio JF, Moscinski LC, Ballester OF, et al. Acute lymphocytic leukemia (ALL) in elderly patients. Hematol Oncol. 1993;11: Kantarjian HM, O Brien S, Smith TL, et al. Results of treatment with hyper-cvad, a dose-intensive regimen, in adult acute lymphocytic leukemia. J Clin Oncol. 2000;18: Larson RA, Stock W, Hoelzer D, et al. Acute lymphoblastic leukemia in adults. In: Hematology, Washington, DC: American Society of Hematology; 1999: Stock W. Treatment of adult acute lymphoblastic leukemia: risk-adapted strategies. In: Hematology, Washington, DC: American Society of Hematology; 1999: Kantarjian HM, O Brien S, Smith TL, et al. Acute lymphocytic leukemia in the elderly: characteristics and outcome with the vincristine-adriamycin-dexamethasone (VAD) regimen. Br J Haematol. 1994;88: Faderl S, Kantarjian HM, Talpaz M, et al. Clinical significance of cytogenetic abnormalities in adult acute lymphoblastic leukemia. Blood. 1998;91: Bloomfield CD, Peterson LC, Yunis JJ, et al. The Philadelphia chromosome (Ph1) in adults presenting with acute leukemia: a comparison of Ph1+ and Ph1 patients. Br J Haematol. 1997;36: Crist W, Carroll A, Shuster J, et al. Philadelphia chromosome positive childhood acute lymphoblastic leukemia: clinical and cytogenetic characteristics and treatment outcome: a Pediatric Oncology Group study. Blood. 1990;76: Ribeiro RC, Abromowitch M, Raimondi SC, et al. Clinical and biologic hallmarks of the Philadelphia chromosome in childhood acute lymphoblastic leukemia. Blood. 1987;70: Specchia G, Mininni D, Guerrasio A, et al. Ph positive acute lymphoblastic leukemia in adults: molecular and clinical studies. Leuk Lymphoma. 1995;18(suppl 1): Schlette E, Bueso-Ramos C, Giles F, et al. Mature B-cell leukemias with more than 55% prolymphocytes: a heterogeneous group that includes an unusual variant of mantle cell lymphoma. Am J Clin Pathol. 2001;115: Kantarjian HM, Talpaz M, Dhingra K, et al. Significance of the p210 versus p190 molecular abnormalities in adults with Philadelphia chromosome positive acute leukemia. Blood. 1991;78: Bennett JM, Catovsky D, Daniel MT, et al. The morphological classification of acute lymphoblastic leukemia: concordance among observers and clinical correlations. Br J Haematol. 1981;47: Hoelzer D, Thiel E, Löffle H, et al. Prognostic factors in a multicenter study for treatment of acute lymphoblastic leukemia in adults. Blood. 1988;71: Secker-Walker LM, Craig JM. Prognostic implications of breakpoint and lineage heterogeneity in Philadelphia-positive acute lymphoblastic leukemia: a review. Leukemia. 1993;7: Nagura E, Minami S, Nagata K, et al. Analysis of elderly patients, aged 60 years old or over, with acute lymphoblastic leukemia [abstract in English]. Nippon Ronen Igakkai Zasshi. 1999;36: Am J Clin Pathol 2002;117: American Society for Clinical Pathology