Multi Cytogenetic Changes in a Patient as Co-Existing MDS and CLL Progresses

Figures & data

Table 1 Documented Clinicopathological Characteristics of Patients Co-Existing CLL and MDS

Subjects	Age	Sex	Karyotype	Classification	OS
Bracey AW et al^Citation3 1989	72	M	t(1;7),-7,+8	MDS-RAEB to AML	5 month
Sylvester LS et al^Citation4 1997	85	M	del(13)(q12q22),+12	MDS-RA	N/A
Lai R et al^Citation5 1999	67	M	Myeloid cells,13q-; Lymphoid cells,+12	MDS-RAS	N/A
Hana A et al^Citation6 2004	63	M	+12, del(14)(q21)[1]/47, XY,+8[1]/46, XY[23].	MDS-RCMD	7 month
Luca Let al^Citation7 2011	83	M	N/A	MDS/MPN	N/A
	74	M
	64	F
Tambaro FP et al^Citation8 2016	N/A	N/A	N/A	MDS	N/A
	N/A	N/A	N/A

Table 2 Patient Characteristics During the Process

Subjects	Initial Test (Dec,25,2015 to Jan,13,2016)	Second Test (Feb,16, 2016 to Mar, 31,2016)	Third Test (May,11, 2016 to May,22,2016)	Fourth Test (Jun,13, 2016 to Jun,29,2016)
Peripheral blood analysis	WBC(65.4x10^9/L), NEU(2.01x10^9/L), LYM(63.12x10^9/L), HGB7.3g/L, PLT(36x 10^9/L)	WBC(0.89x10^9/L), NEU(0.18x10^9/L), LYM(0.66x10^9/L), HGB(6.2g/L), and PLT (6x10^9/L)	WBC(3.69x10^9/L), NEU(2.06x10^9/L), LYM(1.24x10^9/L), HGB (8.0g/L), and PLT (174x10^9/L).	WBC(0.69x10^9/L), NEU(0.03x10^9/L), LYM(0.0.61x10^9/L), HGB(7.7g/L), andPLT(23x10^9/L).
Bone marrow aspiration	Hematopoietic hyperplasia; Mature lymphocytes at 87%; Background trilineage hematopoiesis was reduced with normal morphology.	Hematopoietic hyperplasia; Mature lymphocytes at 21%. Sideroblasts were 35% of all normoblasts. Erythroid series revealed numerous proerythroblast and basophilic erythroblast (56%), with abnormal nucleus easily observed (<10%). Myeloid and megakaryocyte were reduced.	Hematopoietic hyperplasia Mature lymphocytes at 15%. Sideroblasts were 10% of all normoblasts. erythrocytes were active. Parts of erythroblasts were megaloblastic (<10%). Myeloid hyperplasia was reduced. Some unknown cells poorly differentiated with a large body take up 12% of the nucleated cells, PAS(+), MPO(-), highly suspected as small megakaryocytes.	Hematopoietic hyperplasia, a large increase in immature cells with megakaryocyte morphology. Blast cells were poorly differentiated, PAS(+), MPO(-). Granulocyte, erythrocyte, and lymphocyte series were significantly reduced.
Bone marrow biopsy	Hematopoietic area at 90%. Abnormal cells increased in number, containing a large cell body, a moderate amount of cytoplasm, round or oval nucleus. MF-1 level.	Hematopoietic area at 90%. A marked increase in granulocyte and immature erythroid cell and small megakaryocytes. IHC showed CD42b megakaryocytes(+); CD34(-);CD117, CD5, MPO, CD20andCD23 (scattered or clustered+). MF-1 level.	Remarkable fibrous proliferation(MF-2 level). Small megakaryocytes were easy to see. IHC revealed the number of abnormal B cells increased, positive for CD20, CD5, CD23; CD42b megakaryocytes(+);CD34 (<2%); CD117 (a small amount); MPO (a small amount); CD3(-).	Hematopoietic area at 80%. A significant increase in the amount of large body cells with abundant cytoplasm, round or slightly irregular nucleus, thicker nuclear chromatin, and prominent nucleoli, IHC showed negative for CD20, PAX5, CD3, CD138, CD117, CD42b, Ckpan, Cam5.2. Small lymphocytes increased in number and were positive for CD20, PAX5, CD5 and CD23.
Flow cytometry	Lymphocytes represented 75.05% of the nucleated cells, with abnormal small B lymphocytes at 72.29%, positive for CD19, CD23, CD43, Lambda; dim for CD5, CD76, CD81, CD22, SIgD, SIgM, CD38, CD20; and negative for CD10, FMC7, CD11c, CD103, and Kappa.	Lymphocytes taking up 18.46% of all nucleated cells, with abnormal mature small B lymphocytes at 8.25%, positive for CD19, CD20 (a small amount), CD22, CD23, Lambda, and negative for CD10, FMC7, CD34 and Kappa.	Lymphocytes accounting for 16.2% of all nucleated cells, with abnormal mature small B lymphocytes at 26.06%, positive for CD19, CD23, Lambda but negative for CD5, CD10 and Kappa. A marked increase in the quantity of immature erythrocytes (64.08% of nucleated cells), positive for CD235a, CD36 andCD71, negative for CD34.	Lymphocytes taking up 62.71% of all nucleated cells, with abnormal small mature B lymphocyte at 53.22%, positive for CD19, CD20(a small amount), CD22, CD23, Lambda, and negative for CD10, FMC7, CD34 and Kappa with light chain restriction. Juvenile erythrocyte and granulocyte had reduced.
Cytogenetics	66~68, XY,+Y,+1,+1,+2,+3,+3,+4,+6,+6,+7, +8,+9, +11,+12, +13,+15, +16,+17,+21, +21,+21[cp10]/46, XY[3]	46, XY[8]	55~65, XY,+Y, +1,+2, +2,+4, +5,+5,+5,+8, t(9;22)(q24;q11.2),+13,+14,+14,+15,+16, +17, +20,+21,+der(22)t(9;22)[cp14]/46, XY[6]	57~59, XY,+Y,+1,+2,+3,+6,+8, add(11)(p15),+13,+15,+16,+19,+21,+21,+21[cp20].

Figure 1 Tendency of peripheral blood cells during hospitalization and treatment.

Figure 2 Images A & E, B & F, C & G, and D & H show the initial, second, third and fourth bone marrow (BM) aspirate cells smear.(H & E X400) and biopsy pathological tests (H & E X200) respectively. Cells characters: (A) (12/25/2015) Hematopoietic hyperplasia; Mature lymphocytes at 87%; Background trilineage hematopoiesis was reduced with normal morphology (E) (12/25/2015) Hematopoietic area at 90%. Abnormal cells increased in number, containing a large cell body, a moderate amount of cytoplasm, round or oval nucleus. MF-1 level. (B) (03/31/2016) Hematopoietic hyperplasia;Mature lymphocytes at 21%. Iron stain positive Sideroblasts were 35% of all normoblasts. Erythroid series revealed numerous proerythroblasts and basophilic erythroblast (56%), with abnormal nucleus easily observed (<10%). Myeloid and megakaryocyte were reduced. (F) BM biopsy (03/31/2016) demonstrated Hematopoietic area at 90%. A marked increase in granulocyte and immature erythroid cell and small megakaryocytes. Immunohistochemistry showed CD42b megakaryocytes(+); CD34(-);CD117, CD5, MPO, CD20andCD23 (scattered or clustered+). MF-1 level. (C) (05/11/2016) Hematopoietic hyperplasia Mature lymphocytes at 15%. Sideroblasts were 10% of all normoblasts. Erythrocytes were active. Parts of erythroblasts were megaloblastic (<10%). Myeloid hyperplasia was reduced. (G) (05/11/2016) BM biopsy showed increased fibrosis, and granulocyte, erythrocyte, and megakaryocyte cells were easily observed. Lymphocytes were focally or dispersedly distributed. Immunohistochemistry revealed abnormal B cells had increased in quantity, reacting positively for CD20, CD5, CD23, and 42b megakaryocytes, CD34 (<2%), CD117 (a small amount), MPO (a small amount), but negative for CD3 Remarkable fibrous proliferation (MF-2 level). Small megakaryocytes were easy to see. Immunohistochemistry revealed the number of abnormal B cells increased, positive for CD20, CD5, CD23; CD42b megakaryocytes(+); CD34 (<2%); CD117 (a small amount); MPO (a small amount); CD3(-). (D) (06/13/2016) Hematopoietic area at 80%. A significant increase in the amount of large body cells with abundant cytoplasm, round or slightly irregular nucleus, thicker nuclear chromatin, and prominent nucleoli, IHC showed negative for CD20, PAX5, CD3, CD138, CD117, CD42b, Ckpan, Cam5.2. Small lymphocytes increased in number and were positive for CD20, PAX5, CD5 and CD23. (H) BM biopsy showed Lymphocytes taking up 62.71% of all nucleated cells, with abnormal small mature B lymphocyte at 53.22%, positive for CD19, CD20 (a small amount), CD22, CD23, Lambda, and negative for CD10, FMC7, CD34 and Kappa with light chain restriction. Juvenile erythrocyte and granulocyte had reduced.

Figure 3 A, B, C, and D represent the initial, second, third and fourth results taken during conventional cytogenetic analysis of bone marrow. RHG-banded metaphases were analysed and karyotyped according to ISCN (2013). (A) Karyotype on 25 December 2015, LTSC showing:66~68, XY,+Y,+1,+1,+2,+3,+3,+4,+6,+6,+7, +8,+9, +11,+12, +13,+15, +16,+17,+21, +21,+21[cp10]/46, XY[3]. (B) Karyotype on 1 April 2016, USSTC showing less cells with poor proliferation: 46, XY[8]. (C) Karyotype on 11 May 2016, LTSC showing 55~65, XY,+Y, +1,+2, +2,+4, +5,+5,+5,+8, t(9;22)(q24; q11.2), +13,+14, +14,+15, +16, +17,+20,+21,+der(22)t(9;22)[cp14]/46, XY[6]. (D) Karyotype on 14 June 2016, LTSC showing 57~59, XY,+Y,+1,+2,+3,+6,+8, add(11)(p15), +13,+15,+16,+19,+21,+21, +21[cp20].

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