A new adult AML case with an extremely complex karyotype, remission and relapse combined with high hyperdiploidy of a normal chromosome set in secondary AML

Background Chromosomal abnormalities are diagnostic and prognostic key factors in acute myeloid leukemia (AML) patients, as they play a central role for risk stratification algorithms. High hyperdiploidy (HH), a rare cytogenetic abnormality seen commonly in elder male AML patients, is normally categorized under AML with complex karyotype (CK). Accordingly, patients with HH generally are associated with low remission rates and a short overall survival. Case presentation Here we report a case of 21-year-old female, diagnosed with a de novo AML-M1 according to WHO classification and a CK at diagnosis. Cytogenetic, molecular cytogenetic approaches (standard fluorescence in situ hybridization (FISH), array-proven multicolor banding (aMCB)) and high resolution array comparative genomic hybridization (aCGH) analyses revealed a unique complex but still near diploid karyotype involving eleven chromosomes was identified. It included pentasomy 4, three yet unreported chromosomal aberrations t(1;2)(p35;p22), t(1;3)(p36.2;p26.2), and t(10;12)(p15.2;q24.11), and a combination of two cytogenetic events, yet unreported to appear in together, i.e. a reciprocal translocation t(1;3)(p36.2;p26.2) leading to EVI1/PRDM16 gene fusion, and monoallelic loss of tumor suppressor gene TP53. After successful chemotherapeutic treatment the patient experienced a relapse to AML-M1, and she developed secondary AML-M6 with tetraploidy and HH. Unfortunately, the young woman died 8.5 months after initial diagnosis. Conclusions To the best of our knowledge, a comparable adult AML associated with such a CK, coexistence of 3q rearrangements with loss of TP53 at diagnosis, and HH in secondary AML were not previously reported. Thus, the combination of the here seen chromosomal aberrations in adult primary AML seems to indicate for an adverse prognosis.

Approximately 10 to 15% of AML patients had a CK [1,2,4,6,7], which have been associated with a poor prognosis, but were defined differently as the presence of ≥3 and/or ≥ 5 chromosome aberrations [1,2,4,6,7]. CKs, at the cytogenetic level are very heterogeneous and many studies have suggested new definitions based on affected regions or types of aberrations [2,8].
High hyperdiploidy (HH) (i.e. ≥49 chromosomes with or without additional structural rearrangements) is a very rare event observed in small subset of adult AML (< 2%) only [9,10]; it is primarily seen in de novo AML and older male patients with low remission rate and short survival [9]. Interestingly, Chilton et al. [11] indicated that not all HH-AML patients should be automatically classified as having adverse prognosis. Only those patients with the presence of other specific adverse cytogenetic features (for example, − 5 or 5q-, − 7 or 7q-, abnormalities of 3q, translocation t(9;22) and certain MLL translocations) can confidently be assigned to the adverse risk group, whereas those with numerical changes only, should be classified into the intermediate risk group [11].
We present here for the first time a de novo adult AML case with a yet unreported complex karyotype involving eleven chromosomes at diagnosis and a subsequent tetraploidy and HH without all the previously observed changes in a secondary AML.
At this point the first cytogenetic and immunophenotypic data were determined. Flow cytometric (FCM) analysis classified this case as AML-M1. The patient was  -Abdomen CT scan showed pericardial inflammation and splenomegaly (2 cm).
-CT scan for brain was normal.

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The mass behind the retina of the right eye was still present 03 Jan 2017 -Disappeared the previous Mass behind retina. -Relapse.
-She suffered from fever more than 40 C°for more than 3 days, menorrhagia and blurred vision in the right eye.
-Approximately 8.5 months after initial diagnosis she died due to unknown causes.
-No autopsy was performed because she died in her house.
given standard treatment for AML including (3 + 7) induction chemotherapy (Daunorubicin 60 mg/m 2 for 3 days and Cytarabine 200 mg/m 2 for 7 days). On day + 28 of treatment with (3 + 7) protocol, the patient had not responded as expected to the treatment, i.e. her PB revealed pancytopenia/cytopenia (WBC 0.4 × 10 9 /l), anemia (hemoglobin level = Hgb: 9.5 g/dl); thrombocytopenia (Plt 12 × 10 9 /l) and less than 7% blasts in BM aspiration. The patient was given re-induction chemotherapy (ICE protocol: Cytrabin 200 mg/day: day 1 ➔ day 7, Etobside 100 mg/day: day 1 ➔ day 5, and Idarubicin 20 mg/day: day 1 ➔ day 3) and she achieved complete remission on day 30 of ICE protocol treatment (WBC 7.4 × 10 9 /l; Hgb 11.6 g/dl; Plt 183 × 10 9 /l), with less than 4% blasts in BM aspiration. Still the patient suffered from blurred vision in the right eye (retinal detachment sensory serous) during ICE protocol treatment but her karyotype was normal. The patient was given consolidation I chemotherapy (High dose Ara-C = HIDAC: Cytarabine 3 g/m 2 /day; day 1 ➔ day 3; and Methoxantron 20 mg/day; day 1 ➔day 2). Afterwards the patient did not return to the hospital to continue the treatment for 6 weeks. Then she was referred to the hospital again for blurred vision in the right eye and a mass under the vascular arch with splint edema of optical nerve of the right eye was diagnosed, being the cause of her severe decrease in vision. While cerebrospinal fluid (CSF) test was negative, BM aspiration revealed 20-30% of blasts. In PB WBC was 5.6 × 10 9 /l (98.5% of neutrophils), Hgb was 11.6 g/dl, Plt of 70 × 10 9 /l indicated for thrombocytopenia while CT scan of brain was normal. Now she treated with consolidation II chemotherapy (HIDAC), 2 weeks later her PB had WBC 0.1 × 10 9 /l, Hgb 8.4 g/dl and Plt still 20 × 10 9 /l; the mass behind the retina of the right eye was still present. About 2 months later the patient relapsed and the following values were found: in PB WBC was 7.5 × 10 9 /l with 77.7% of neutrophils, Hgb 12 was g/dl and Plt was 178 × 10 9 /l; BM aspiration revealed 15% of blasts. The MD's suggested to apply now the Flag-Ida protocol; however, due to the political situation in her home country only available treatment at this point was treatment with Cytrabin 100 mg/day. Again 2 weeks later the patient suffered from blurred vision of the right eye due to serious central retinal detachment; her PB revealed a WBC of 60 × 10 9 /l (70% of them were blasts), Hgb of 13.3 g/dl; thrombocytopenia with Plt of 13 × 10 9 /l was present with a normal brain MRI. Now the patient treated with Cytrabin 1 g/day: day 1 ➔ day 3, Etoposide 100 mg/day: day 1 ➔ day 3, and Methoxantron 20 mg/day: day 1 ➔day 2).
Ten days later, the patient relapsed; her PB shows cytopenia [WBC 1.5 × 10 9 /l with 44% blasts)], anemia (Hgb 9.6 g/ dl) and thrombocytopenia (Plt 17 × 10 9 /l). Now the patient stopped the treatment on her own request for 1 month. Afterwards she suffered from fever (more than 40°C for more than 3 days), menorrhagia and blurred vision in the right eye. Approximately 8.5 months after initial diagnosis she died in her house and no autopsy was performed. Her husband agreed with scientific evaluation of her case and the study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria.
Conventional cytogenetics analysis on unstimulated BM sample according to standard procedures was performed [12] prior and post chemotherapy treatments. Karyotypes according to the International System for Human Cytogenetic Nomenclature were classified [13].

Discussion and conclusions
To the best of our knowledge we report here the first case of a patient with an AML-M1 relapsing with a secondary AML-M6. In AML-M1 the patient presented a CK involving eleven chromosomes and yet unreported acquired chromosomal aberrations, while in AML-M6 a completely different, two-clonal karyotype with tetraploidy and HH was observed.
Gains of chromosomes, in particular tetrasomies 4, 8, 13, 14, 20 and 21, as well as pentasomies 13, 21 and 22, have been observed in AML rarely. However, there was no influence on survival observed according to the number or types of trisomies or tetrasomies [19]. Also, tetraploidy (4n, 92 chromosomes) has not previously been reported in secondary AML cases; only Harrison et al. [20] described a hypotetraploid case in a secondary AML, which had an adverse outcome.
In general, HH and tetraploidy appears infrequently in AML; it seen primarily in de novo disease in older male patients (> 60 years) with low remission rates and short overall survival (OS) [9,10]. Unfortunately only limited data on incidence and clinical implications of HH and tetraploidy in AML is available. Still, most of comparable     abnormalities [14]. Additionally, AML patients with ≥3 three unrelated aberrations had a worse outcome than normal karyotype patients [19]. Thus, it was repeatedly suggested in contrast to main stream [1,5,6], to reclassify AML patients in risk categories according to chromosomal aberrations rather than e.g. only HH [11; 18]. Stölzel et al. [19] proposed to distinguish HH patients with up to three aberrations without specific adverse-risk abnormalities, from those with more than 4 aberrations. Concerning aberrations observed in the present case there was specifically in AML-M1 monoallelic losses for TP53, ETV6, BRCA1 genes and or gain of copy numbers for EVI1 (ecotropic viral integration site-1) gene. TP53 gene mutation is observed in approximately 5-10% of all AML cases, occurring frequently in elderly subjects and cases with FAB classification M6, as well as in cases with CK; it is associated with unfavorable prognosis [21]. Aberrant expression of EVI1 gene occurs in approximately 6-8% of AML cases and has been associated with poor treatment outcome [22,23]. The EVI1 gene maps to chromosomal band 3q26.2 and was first identified to be aberrantly upregulated in almost all AML cases with t(3;3)(q21;q26.2) [17] or inv.(3)(q21q26.2) [24,25]. In our case with the t(1;3)(p36.21;p26.2), the EVI1 locus at 3q26 is translocated to PRDM16 (MEL1; MDS1/EVI1-like-1) at 1p36, being highly homologous to EVI1 (PRDM3) [26]. In concordance with the conditions seen in the present case t(3;v)(q26;?) translocation was associated with younger age AML; here, the complete remission rate has been reported to be < 50% and long-term OS < 10% [25].
According to the literature the here observed, we report the first AML-M1 case relapsing to a completely independent biclonal secondary AML-M6 case. Adverse outcome of the case may be partially caused by adverse mutations in AML-M1 like TP53 deletion and translocation t(1;3)(p36.2;p26.2) involving EVI1 gene, but also by HH. ICE therapy might have been helpful here, however, due to interrupted treatment this cannot be finally assessed.