Modern Pathologyhttps://doi.org/10.1038/s41379-018-0014-x

ARTICLE

Secondary Philadelphia chromosome acquired during therapy ofacute leukemia and myelodysplastic syndrome

Habibe Kurt1 ● Lan Zheng1● Hagop M. Kantarjian2

● Guilin Tang1● Farhad Ravandi-Kashani2 ●

Guillermo Garcia-Manero2● Zimu Gong1

● Hesham M. Amin1● Sergej N. Konoplev1 ● Mark J. Routbort1 ● Xin Han3

●

Wei Wang1● L. Jeffery Medeiros1 ● Shimin Hu 1

Received: 3 October 2017 / Revised: 29 November 2017 / Accepted: 3 December 2017© United States & Canadian Academy of Pathology 2018

AbstractThe Philadelphia chromosome resulting from t(9;22)(q34;q11.2) or its variants is a defining event in chronic myeloidleukemia. It is also observed in several types of de novo acute leukemia, commonly in B lymphoblastic leukemia, and rarelyin acute myeloid leukemia, acute leukemia of ambiguous lineage, and T lymphoblastic leukemia. Acquisition of thePhiladelphia chromosome during therapy of acute leukemia and myelodysplastic syndrome is rare. We reported 19 patients,including 11 men and 8 women with a median age of 53 years at initial diagnosis. The diagnoses at initial presentation wereacute myeloid leukemia (n= 11), myelodysplastic syndrome (n= 5), B lymphoblastic leukemia (n= 2), and Tlymphoblastic leukemia (n= 1); no cases carried the Philadelphia chromosome. The Philadelphia chromosome wasdetected subsequently at relapse, or at refractory stage of acute leukemia or myelodysplastic syndrome. Of 14 patientsevaluated for the BCR-ABL1 transcript subtype, 12 had the e1a2 transcript. In 11 of 14 patients, the diseases before and afteremergence of the Philadelphia chromosome were clonally related by karyotype or shared gene mutations. Of 15 patients withtreatment information available, 7 received chemotherapy alone, 5 received chemotherapy plus tyrosine kinase inhibitors, 2received tyrosine kinase inhibitors only, and 1 patient was not treated. Twelve patients had follow-up after acquisition of thePhiladelphia chromosome; all had persistent/refractory acute leukemia. Thirteen of 15 patients died a median of 3 monthsafter the emergence of the Philadelphia chromosome. In summary, secondary Philadelphia chromosome acquired duringtherapy is rare, and is associated with the e1a2 transcript subtype, terminal disease stage, and poor outcome.

Introduction

The Philadelphia chromosome resulting from t(9;22)(q34;q11.2) or its variants is the hallmark of chronic myeloidleukemia [1]. It is also observed in several types of de novo

acute leukemia, commonly in B lymphoblastic leukemia[2], and rarely in acute myeloid leukemia [3–5], acuteleukemia of ambiguous lineage [6, 7], and T lymphoblasticleukemia [8, 9]. Different break point sites within the BCRgene result in different BCR-ABL1 fusion transcript sub-types that may affect the disease phenotype. The typicalb2a2/b3a2 fusion transcripts, which encode P210, are foundin over 95% of patients with chronic myeloid leukemia. Thee1a2 fusion transcript, which encodes P190, is seen in mostpatients with Philadelphia chromosome-positive B lym-phoblastic leukemia, and is associated with monocytosis inchronic myeloid leukemia [10]. Patients with chronicmyeloid leukemia and the e1a2 transcript have a higher riskof blastic transformation, poor treatment response, andunfavorable survival compared with patients with the typi-cal b2a2/b3a2 transcripts [11]. Cases of chronic myeloidleukemia that carry the rare e19a2 transcript, which encodesP230, often show prominent neutrophilic maturation orthrombocytosis [12, 13].

* Shimin Hushu1@mdanderson.org

1 Department of Hematopathology, The University of Texas MDAnderson Cancer Center, Houston, TX, USA

2 Department of Leukemia, The University of Texas MD AndersonCancer Center, Houston, TX, USA

3 Department of Laboratory Medicine, The University of Texas MDAnderson Cancer Center, Houston, TX, USA

Electronic supplementary material The online version of this article(https://doi.org/10.1038/s41379-018-0014-x) contains supplementarymaterial, which is available to authorized users.

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5678

90();,:

All subtypes of BCR-ABL1 transcripts encode fusion pro-teins with constitutive tyrosine kinase activity that is essentialfor inducing leukemia via increasing tumor cell proliferationand growth, reducing adherence to bone marrow stroma [1],and promoting angiogenesis, metastasis, and a defectiveapoptotic response [14]. An understanding of the abnormalsignaling pathway has led to the development of smallmolecule tyrosine kinase inhibitors targeting BCR-ABL1.This targeted therapy has dramatically improved the outcomeof patients with chronic myeloid leukemia [15], and to a lesserextent, Philadelphia chromosome-positive B lymphoblasticleukemia [16–18]. Improved survival in patients with de novoPhiladelphia chromosome-positive acute myeloid leukemiahas also been reported anecdotally [19].

Myeloid and lymphoid neoplasms in which the Phila-delphia chromosome appears as a primary change at diseaseonset are well-established entities, and have been exten-sively studied. However, secondary Philadelphia chromo-some acquired during therapy of myeloid or lymphoidneoplasms is extremely rare, and only sporadically descri-bed in the form of single-case reports in the literature [20–53]. The biological and clinical features of these cases havenot been systematically studied, and the prognostic sig-nificance of secondary Philadelphia chromosome is poorlyunderstood. Here, we reported 19 patients who acquired thePhiladelphia chromosome during therapy of myeloid orlymphoid neoplasms and provided an overview of casesreported in the literature.

Methods

Patient selection

Patients with myeloid or lymphoid neoplasms diagnosed inour institution from 1998 through 2016 were reviewed forthe presence of the Philadelphia chromosome acquiredduring therapy. Patients with following Philadelphiachromosome-positive diseases were not included: chronicmyeloid leukemia, de novo B- or T lymphoblastic leukemia,de novo acute myeloid leukemia, and de novo acute leu-kemia of ambiguous lineage. Patient demographics, clinicalhistories, including treatment and follow-up information,and laboratory data were obtained by electronic chartreview. This study was approved by the InstitutionalReview Board at the University of Texas MD AndersonCancer Center and was conducted in accordance with theDeclaration of Helsinki.

Flow cytometric immunophenotyping

Flow cytometric immunophenotypic analysis was per-formed on bone marrow aspirates using standard multicolor

analysis, which evolved substantially during the studyinterval. The following antibodies were used in variouscombinations: CD2, CD3 (surface and cytoplasmic), CD4,CD5, CD7, CD13, CD14, CD15, CD19, CD20, CD22,CD25, CD33, CD34, CD36, CD38, CD41, CD45, CD56,CD64, CD117, CD123, HLA-DR, MPO, and TDT (Becton-Dickinson, Biosciences, San Jose, CA, USA). Data wereanalyzed using FCS Express (De novo Software, Glendale,CA).

Cytogenetic studies

Conventional chromosomal analysis was performed on G-banded metaphase cells prepared from unstimulated bonemarrow aspirate cultures (24 and 48 h) using standard GTGbanding. At least 20 metaphases were analyzed. Resultswere reported using the 2013 International System forHuman Cytogenetic Nomenclature [54]. Fluorescencein situ hybridization (FISH) analysis for BCR-ABL1 fusionwas performed on freshly harvested aspirate smears orcultured cells with LSI-BCR-ABL1 ES fusion probes(Abbott Molecular/Vysis, Des Plaines, IL) using previouslydescribed methods [55]. At least 200 interphase nuclei wereanalyzed.

Detection of BCR-ABL1 transcripts

Reverse transcription-quantitative polymerase chain reac-tion (PCR) for detection of BCR-ABL1 transcripts [e1a2,e13a2 (b2a2), and e14a2 (b3a2)] was performed using RNAextracted from bone marrow or peripheral blood sampleswith sensitivities of 1 in 10,000 and 1 in 100,000, respec-tively, according to methods described previously [56, 57].Quantitative results were expressed as the percent ratio ofBCR-ABL1 to ABL1. The sizes of fusion transcripts weredetermined by capillary electrophoresis.

Mutation analysis

Mutation analysis was performed using DNA extractedfrom bone marrow aspirate samples in a subset of patientsusing the following techniques. Next-generation sequen-cing-based analysis was performed to detect somaticmutations in the entire coding sequences of 28 genes(ABL1, EGFR, GATA2, IKZF2, MDM2, NOTCH1, RUNX1,ASXL1, EXH2, HRAS, JAK2, MLL, NPM1, TET2, BRAF,FLT3, IDH1, KIT, MPL, NRAS, TP53, DNMT3A, GATA1,IDH2, KRAS, MYD88, PTPN11, WT1) or in hotspots of 53genes (ABL1, CSF1R, FGFR1, HRAS, KRAS, PIK3CA,SRC, AKT1, CTNNB1, FGFR2, IDH1,MET, PTEN, STK11,ALK, DNMT3A, FGFR3, IDH2, MLH1, PTPN11, TP53,APC, EGFR, FLT3, JAK2, MPL, RB1, VHL,ATM, ERBB2,GNA11, JAK3, NOTCH1, RET, XPO1,BRAF, ERBB4,

H. Kurt et al.

Table1

Clin

ical

characteristicsof

patientswith

second

aryPhiladelphiachromosom

e

No.

Initial

Dx

Sex/age

(years)

Dxat

Phem

ergence

Interval

toPh

(mon

ths)

BCR-A

BL1

transcript

Txandrespon

sebefore

Ph

Txandrespon

seafterPh

OSfrom

Ph

(mon

ths)

Patient

status

Disease

status

1AML

M/22

AML,1strelapse

9e1a2

Chemo

Chemo

1Dead

Refractory

CR

Norespon

se

2AML

F/31

AML,3rdrelapse

17e1a2

Chemo,

HSCT

Chemo,

sorafenib

3Dead

Refractory

CR

Norespon

se

3AML

F/26

AML,3rdrelapse

26b3

a2andb2

a2Chemo,

HSCT

Chemo,

dasatin

ib,

ponatin

ib4

Dead

Refractory

CR

Norespon

se

4AML

F/57

AML,3rdrelapse

26e1a2

Chemo,

HSCT

Chemo,

dasatin

ib4

Dead

Refractory

CR

Norespon

se

5AML

F/66

AML,1strelapse

9NA

Chemo,

HSCT

Chemo

1Dead

Refractory

CR

Norespon

se

6AML

M/63

AML,refractory

9b2

a2Chemo

Chemo,

dasatin

ibNA

Lostin

F/U

NA

Norespon

seInitial

respon

se

7AML

M/65

AML,2n

drelapse

15e1a2

Chemo

Chemo,

dasatin

ib9

Dead

Refractory

CR

Norespon

se

8AML

M/52

AML,refractory

6NA

Chemo

Chemo

4Dead

Refractory

Norespon

seNorespon

se

9AML

M/28

AML,1strelapseand

prog

ression

18NA

Chemo

Chemo

NA

Lostin

F/U

NA

Norespon

seNA

10AML

M/42

AML,3rdrelapseand

prog

ression

14e1a2

Chemo,

HSCT

Chemo

5Dead

Refractory

Norespon

seNorespon

se

11AML

M/39

AML,refractory

11e1a2

Chemo

Chemo

8Aliv

eRefractory

Norespon

seNorespon

se

12MDS

F/48

sAML,2n

drelapse

14e1a2

Chemo

Chemo

2Dead

Refractory

CR

Norespon

se

13MDS

F/58

sAML,prog

ression

72e1a2

Chemo

NA

NA

Lostin

F/U

NA

Progression

14MDS

M/78

sAML,1strelapse,

then

persistent

MDS

20NA

Chemo

NA

NA

Lostin

F/U

NA

CR

15MDS

M/69

sAML,refractory

38NA

Chemo

Notreatm

ent

1Dead

Refractory

Refractory

Secondary Philadelphia chromosome acquired during therapy

GNAQ, KDR, NPM1, SMAD4, CDH1, EZH2, GNAS, KIT,NRAS, SMARCB1, CDKN2A, FBXW7, HNF1A, KLHL6,PDGFRA, SMO1). The next-generation sequencing assayswere performed using the Illumina MiSeq sequencer (Illu-mina, San Diego, CA) with a sensitivity of 5% as describedpreviously [58, 59]. FLT3-ITD, FLT3 D835, and NPM1(exon 12, codons 956–971) mutations were assessed byPCR followed by capillary electrophoresis on a geneticanalyzer (Prism ABI 3130, Applied Biosystems, FosterCity, CA) as described previously [60]. NRAS (codons 12,13, 61), KRAS (codons 12, 13, 61), IDH1 (exon 4, codons87–138), IDH2 (exon 4), KIT (exons 8 and 17), and JAK2(codon 617) mutations were assessed by PCR followed bySanger sequencing with a sensitivity of 20% as describedpreviously [58, 61]. PCR-based cDNA sequencing of BCR-ABL1 was performed to detect mutations in codons221–500 of the ABL1 kinase domain by using pyr-osequencing PSQ96 HS System (Biotage AB, Uppsala,Sweden) per the manufacturer’s instructions. The lowerlimit of detection of the assay is 5% mutation-bearing cellsin the test samples. PCR-based microsatellite polymorphismanalysis was performed by using GENESCAN on the pre-transplant, donor, and post-transplant samples.

Results

Timing of emergence of secondary Philadelphiachromosome

A total of 19 patients were identified to have secondary t(9;22)(q34;q11.2)/BCR-ABL1 detected by chromosomalbanding analysis during therapy of acute leukemia ormyelodysplastic syndrome. The diagnoses at initial pre-sentation were acute myeloid leukemia (n= 11), myelo-dysplastic syndrome (n= 5), B lymphoblastic leukemia (n= 2), or T lymphoblastic leukemia (n= 1) (Table 1). Novariant BCR-ABL1 rearrangements were identified. Therewere 11 men and 8 women with a median age of 53 years(range, 18–78 years) at initial diagnosis, and 56 years(range, 19–79 years) at time of emergence of secondaryPhiladelphia chromosome.

Of the 11 patients with an initial diagnosis of acutemyeloid leukemia, 6 patients acquired secondary Philadel-phia chromosome at time of first to 3rd relapse, 2 acquiredsecondary Philadelphia chromosome during progression ofacute myeloid leukemia after 1–3 relapses, and 3 acquiredsecondary Philadelphia chromosome during treatment ofrefractory disease (patients never achieved remission beforethe emergence of secondary Philadelphia chromosome)(Table 1). Of the five patients with an initial diagnosis ofmyelodysplastic syndrome, all developed secondary acutemyeloid leukemia, and acquired the PhiladelphiaTa

ble1(con

tinued)

No.

Initial

Dx

Sex/age

(years)

Dxat

Phem

ergence

Interval

toPh

(mon

ths)

BCR-A

BL1

transcript

Txandrespon

sebefore

Ph

Txandrespon

seafterPh

OSfrom

Ph

(mon

ths)

Patient

status

Disease

status

16MDS

M/62

sAML,1strelapseand

Refractory

42e1a2

Chemo

Imatinib,nilotin

ib3

Dead

Refractory

Refractory

Norespon

se

17B-A

LL

M/64

B-A

LL,1strelapse

26e1a2

ChemoCR

Chemo,

bosutin

ib,

HSCTCR

6Aliv

eCR

18B-A

LL

F/53

B-A

LL,1strelapseand

refractory

t-AML

40e1a2

Chemo

Imatinib

with

CR

and

refractory

t-AML

4Dead

Refractoryt-

AML

Norespon

se

19T-A

LL

F/18

2ndrelapseandrefractory

19e1a2

Chemo

Chemo

1Dead

Refractory

Refractory

Norespon

se

Dxdiagno

sis,Txtreatm

ent,PhPhiladelphiachromosom

e,Interval

intervaltim

efrom

initialdiagno

sisto

theem

ergenceof

Ph,

OSov

erallsurvival,AMLacutemyeloid

leuk

emia,sAMLsecond

ary

AML,M

DSmyelody

splasticsynd

rome,B-ALLBlymph

oblasticleuk

emia,T

-ALLTlymph

oblasticleuk

emia,t-AMLtherapy-relatedAML,M

male,Ffemale,Chemochem

otherapy

,CRcomplete

remission

,HSC

Thematop

oietic

stem

celltransplantation,

F/U

follo

w-up,

NAno

tavailable

H. Kurt et al.

chromosome when secondary acute myeloid leukemiadeveloped (n= 1), relapsed (n= 1), relapsed and becamerefractory to treatment (n= 2), or after relapse with per-sistent myelodysplastic syndrome (1% blasts in bone mar-row) (n= 1). The two patients with an initial diagnosis of Blymphoblastic leukemia acquired the Philadelphia chromo-some at relapse or at a refractory stage after relapse,respectively. In the patient with T lymphoblastic leukemia,the Philadelphia chromosome was acquired during treat-ment of refractory disease after two relapses. Among thepatients with an initial diagnosis of acute myeloid leukemiaor acute lymphoblastic leukemia, the median interval fromthe initial diagnosis of acute leukemia to the acquisition ofsecondary Philadelphia chromosome was 16 months (range,6–40 months). Among the patients with an initial diagnosisof myelodysplastic syndrome, the median interval from theinitial diagnosis of myelodysplastic syndrome to the

emergence of secondary Philadelphia chromosome was38 months (range, 14–72 months), and the median intervalfrom the development of secondary acute myeloid leukemiato the emergence of secondary Philadelphia chromosomewas 9 months (range, 0–37 months).

Complete blood count data and bone marrowmorphology after acquisition of Philadelphiachromosome

At emergence of secondary Philadelphia chromosome, 18patients had anemia (range, 8.4–11.5 g/dl), 16 had throm-bocytopenia (range, 8–104× 103/μ), and 8 had leukopenia(range, 1.0–3.8× 103/μl) (Supplemental Table 1). Circu-lating blasts (range, 2–96%) were seen in 15 patients. Ineight patients who had leukocytosis (range, 13.9–89.2×103/μl), blasts were the predominant cell population in five

Fig. 1 Morphology of blastsbefore and after emergence ofsecondary BCR-ABL1. a, b Blastmorphology of patient withacute myeloid leukemia (#8)before (a) and after (b) theemergence of secondary BCR-ABL1. c, d Blast morphology ofpatient with myelodysplasticsyndrome (#16) before (c) andafter (d) the emergence ofsecondary BCR-ABL1. e, f Blastmorphology of patient with Tlymphoblastic leukemia (#19)before (e) and after (f) theemergence of secondary BCR-ABL1. Original magnification:x1000

Secondary Philadelphia chromosome acquired during therapy

patients. Six patients had absolute monocytosis at the timeof emergence of secondary Philadelphia chromosome, andfour of them had monocytosis before acquisition of thePhiladelphia chromosome. Absolute eosinophilia, basophi-lia, and left-shifted granulocytes, features of chronic mye-loid leukemia, were observed in only one patient (#13).

Bone marrow smears both before and after detection ofsecondary Philadelphia chromosome were available forretrospective review in nine patients. There was no changein the morphology of blasts before versus after emergenceof secondary Philadelphia chromosome (Fig. 1), except inpatient #1 whose blasts appeared more monoblastic atdetection of secondary Philadelphia chromosome [62]. Noimmunophenotypic shift in the blasts was detected by flowcytometric analysis in 14 patients with available data (#1, 2,4, 5, 6, 7, 9, 11, 12, 13, 16, 17, 18, and 19). Given theevolving nature of flow cytometry methods over the courseof this study, however, blasts were evaluated with only alimited number of markers in early cases.

Clonal relatedness between diseases before and atemergence of secondary Philadelphia chromosome

Detailed cytogenetic and molecular findings at initialdiagnosis, and before and after the emergence of secondaryPhiladelphia chromosome are provided in Tables 2 and 3.

Karyotypes at initial diagnosis were available in 16patients (Table 2). Seven patients had a normal karyotypeand nine had an abnormal karyotype. In seven of ninepatients with an abnormal karyotype at initial diagnosis, theinitial chromosomal alterations were present in the sec-ondary Philadelphia chromosome-positive clones, thus thediseases before and at the emergence of the Philadelphiachromosome were clonally related, and the emergence ofsecondary Philadelphia chromosome may represent clonalevolution.

In five of seven patients with a normal karyotype, testsfor molecular mutations with a limited panel were per-formed in bone marrow samples obtained before and at timeof emergence of secondary Philadelphia chromosome.Common molecular mutations were detected before and atemergence of secondary Philadelphia chromosome in fourpatients (Table 3). FLT3-ITD mutation in patients #2 and10, NPM1 mutation in patient #4, and NRAS mutation inpatient #6. Of note, the post-transplant microsatellite poly-morphism pattern showed a mixed chimera in three patientstested (#2, 4, and 5), supporting the recipient origin ofrelapsed disease.

BCR-ABL1 transcript subtype and ABL1 mutation

FISH analyses were performed in 16 patients, and BCR-ABL1 rearrangement was confirmed positive in all. In 14

patients tested by reverse transcription-quantitative PCR forBCR-ABL1 transcript subtype, the e1a2 fusion transcripts(P190) were identified in 12 patients (86%). In the other twopatients (#3 and 6), b2a2 or simultaneous b2a2 and b3a3transcripts were identified, respectively. Of five patientsanalyzed for ABL1 kinase domain mutations (#2, 3, 7, 16,and 17), only one (#7) showed a mutation (p.G254E)(Table 3).

Evolution of secondary Philadelphia chromosome-positive clones during therapy

Before the emergence of secondary Philadelphia chromo-some detectable by chromosomal banding analysis, BCR-ABL1 rearrangement or fusion transcripts were tested ineight patients by either FISH (n= 3) or reversetranscription-quantitative PCR (n= 4) or both (n= 1). Alow level of BCR-ABL1 fusion transcripts was detected inthree patients either at initial presentation (#1, 0.11%; #11,0.01%) or later during therapy (#18, 0.70%) by reversetranscription-quantitative PCR, but not by FISH. The BCR-ABL1 transcript subtype was of e1a2 in all three patients.The median time from the detection of low level of BCR-ABL1 by reverse transcription-quantitative PCR to theemergence of secondary Philadelphia chromosome detectedby karyotyping was 9 months (range, 5–11 months).

After the emergence of secondary Philadelphia chromo-some detected by karyotyping, the Philadelphiachromosome-positive subclones were the major one in 11patients, simultaneously with the emergence of secondaryPhiladelphia chromosome in eight patients (#1, 6, 7, 9, 13,16, 17, and 19) and shortly after the emergence of sec-ondary Philadelphia chromosome in three patients (#4, 12,and 18). The Philadelphia chromosome-positive subcloneswere a minor clone in the remaining eight patients. Twelvepatients had follow-up information on the evolution ofPhiladelphia chromosome-positive subclones after initialdetection. The Philadelphia chromosome-positive subcloneswere persistent by FISH analysis in six patients (#2, 6, 8,11, 12, and 16) despite chemotherapy with or without tyr-osine kinase inhibitors. In the remaining six patients (#3, 4,7, 10, 17, and 18), the Philadelphia chromosome-positivesubclones were undetectable by FISH analysis, includingthree patients (#4, 10, and 17) with undetectable BCR-ABL1transcripts by reverse transcription-quantitative PCR. Ofthose six patients with undetectable Philadelphiachromosome-positive subclones, five were treated withtyrosine kinase inhibitors and one received conventionalchemotherapy. Interestingly, all 12 patients had persistent orrefractory acute myeloid leukemia or acute lymphoblasticleukemia regardless of the presence or absence of the Phi-ladelphia chromosome-positive subclones, including onepatient (#18) with refractory therapy-related acute myeloid

H. Kurt et al.

Table2

Secon

dary

BCR-ABL1detected

bykaryotyp

ing,

FISH,andmolecular

analyses

No.

Atinitial

Dxa

Immediately

before

emergenceof

Ph

Atandafterem

ergenceof

Ph

146

,XY,t(3;13

)(q2

7;q1

4)[1]/45

,XY,t(3;13

)(q2

7;q1

4),−

7[19]

46,XY

[20]

Initial:45

,XY,t(3;13

)(q2

7;q1

4),-7[3]/45

,XY,t(3;13

)(q2

7;q1

4),-7,t(9;22

)(q3

4;q1

1.2)

[14]/46,XY

[3]

FISH(−

);Q-PCR(+

):0.1%

FISH(+

):50

%

246

,XX

[20];

46,XX

[1]/46

,XY

[19]

b1.

Initial:46

,XX,t(9;22

)(q3

4;q1

1.2)

[7]/46

,XX

[2]/46

,XY

[11];FISH(+

):9%

Q-PCR(−

)at

1strelapse

2.RefractoryAML,6wkafterPh,

before

sorafenib:

FISH(+

):68

%;Q-PCR

(+):55

.33%

3NA

46,XX,t(2;17

)(p2

1;p1

1.2),t(14

;17)(q24

;q25

)[16]/46,XX

[4]b

1.Initial:46

,XX,del(2)(p2

3),add

(14)(q11

.2),−17

,+mar

[8]/46

,idem

,t(9;22

)(q34

;q11

.2)[2]/46

,idem

[cp4

]/46

,XX,del(1)(q4

2),del(11)(q13

q23)

[4]/46

,XX

[2];FISH(+

):6.5%

;Q-PCR(+

),9.28

%

2.PersistentAML,11

wkafterPh,

7wkafterpo

natin

ib;FISH(−

)

446

,XX

[20]

46,XY

[20]

b1.

Initial:46

,XX,t(9;22

)(q3

4.1;q1

1.2)

[5]//46,XY

[15]

FISH(+

):6.5%

FISH(−

)at

2ndrelapse

2.PersistentAML,4wkafterPh:

Q-PCR(+

):80

.92%

3.PersistentAML,10

wkafterPh/7wkafterdasatin

ib:Q-PCR(−

)

548

,XX,+

6,+8[18]/46,XX

[2]

46,XX

[19]

bInitial:46

,XX,t(15

;17)(q15

;q11

)[8]/46

,XX,t(2;7)(p21

;q36

),t(9;22

)(q3

4;q1

1.2),add

(12)(p11

.2),t(15

;17)(q15

;q11

)[4]/46

,X,t(X;15;17

)(p2

2;q1

5;q1

1)[8]

646

,XY

[20];Q-PCR(-)2mon

thslater

46,XY

[20]

1.Initial:46

,XY,t(9;22

)(q3

4;q1

1.2)

[15]/46,XY

[5];FISH(+

):39

%;Q-PCR

(+)

2.PersistentAML,2wkafterPh,

before

dasatin

ib:FISH(+

):48

%

746

,XY,in

v(16

)(p1

3q22

)[20]

46,XY,?del(16

)(q2

2)[3]/46

,XY

[17]

1.Initial:46

,XY,in

v(16

)(p1

3q22

)[2]/48

,idem

,t(9;22

)(q3

4;q1

1.2),+

13,+

22[16]/47,XY,in

v(16

)(p1

3q22

),+13

[1]/48

,XY,in

v(16

)(p1

3q22

),+13

,+22

[1]

FISH(+

):4.5%

Q-PCR(+

):8.81

%

2.PersistentAML,8wkafterPh,

4wkafterdasatin

ib:Q-PCR(+

):<0.01

%

845

,XY,in

v(3)(q21

q26.2),−

7[10]/46,XY

[10]

45,XY,in

v(3)(q21

q26.2),−

7[20];FISH(−

)Initial:45

,XY,in

v(3)(q21

q26.2),−

7[19]/44,XY,in

v(3)(q21

q26.2),−

7,t(9;22

)(q34

;q11

.2),−18

[1];FISH(+

):2.5%

946

,XY

46,XY

[19]

Initial:46

,XY,t(9;22

)(q3

4;q1

1.2)

[14]/46–

47,XY,del(3)(p1

3),t(9;22

)(q3

4;q1

1.2),+

mar[cp4

]/46

,XY

[2]

1046

,XY

46,XY

b1.

Initial:46

,XY,del(20)(q11

.2q1

3.3)

[3]/46

,XY,t(9;22

)(q3

4;q1

1.2)

[1]/46

,XY,t(1;16

)(p3

3;q2

4)[1]/46

,XY

[15];FISH(+

):0.4%

2.PersistentAML,6wkafterPh;

Q-PCR(−

)

1145

,XY,in

v(3)(q21

q26.2),−

7[19]/45,idem

,t(5;12

)(q3

1;p1

3)[1]Q-PCR(+

):0.01

%45

,XY,in

v(3)(q21

q26.2),−

7[19]/45

,idem

,t(11;17

)(p1

1.2;p1

1.2)

[1]

1.Initial:8/10

/201

645

,XY,in

v(3)(q21

q26.2),−

7[14]/45,idem

,t(9;22

)(q3

4;q1

1.2)

[5]/45

,idem

,t(11

;17)(q11

.2;q11

.2)[1]

2.RefractoryAML,6

wkafterPh:

45,XY,in

v(3)(q21

q26.2),−

7[19]/46,idem

,+21

[1];FISH(+

):3%

12NA

45,XX,del(5)(q1

3q33

),inv(6)(p11

.2q2

1),add(7)

(p15

),−13

[10]//4

6,XX

[10]

1.Initial:45

,XX,del(5)(q1

3q33

),inv(6)(p11

.2q2

1),add

(7)(p1

5),−

13[3]/45

,idem

,t(9;22

)(q3

4;q1

1.2)

[6]/45

,idem

,17,mar

[1]/46

,XX

[10];FISH(+

):21

%

Secondary Philadelphia chromosome acquired during therapy

Table2(con

tinued)

No.

Atinitial

Dxa

Immediately

before

emergenceof

Ph

Atandafterem

ergenceof

Ph

2.RefractoryAML,8

wkafterPh,before

dasatin

ib:45,XX,del(5)(q1

3q33

),inv

(6)(p1

1.2q

21),add(7)(p15

),t(9;22

)(q3

4;q2

2.1),−

13[20];FISH(+

):94

%;Q-

PCR(+

):>10

0%13

46,XX,t(1;12

)(p1

3;q1

5)[20]

46,XX,t(1;12

)(p1

3;q1

5)[20]

Initial:46

,XX,t(1;12

)(p1

3;q1

5)?c

[3]/46

,XX,t(1;12

)(p1

3;q1

5)?c,t(9;22

)(q3

4;q1

1.2)

[17]

FISH(+

):66

%;Q-PCR(+

):77

.93%

1447

,XY,+

8NA

Initial:46

,XY,t(9;22

)(q3

4;q1

1.2)

[3]/47

,XY,+

8[7]/46

,XY

[10]

1547

,XY,+

2147

,XY,+

21[12]/46,XY

[8]

Initial:47

,XY,in

v(17

)(q1

1.2q

23),+21

[2]/47

,idem

,t(9;22

)(q3

4;q1

1.2)

[2];

FISH(+

):4.5%

16NA

46,XY,t(3;21

)(p2

1;q2

2)[8]/46

,XY

[12]

1.Initial:46

,XY,t(9;22

)(q3

4;q1

1.2)

[17]/46,XY,der(9)t(9;22)(q34

;q11

.2)inv

(9)(p1

2q32

),der(22

)t(9;22)

[2]

2.RefractoryAML,5wkafterPh,

4wkafterim

atinib:46

,XY,t(9;22

)(q3

4;q1

1.2)

[18]/46

,XY,der(9)t(9;22)(q34

;q11

.2)inv

(9)(p1

2q32

),der(22

)t(9;22)

[1];FISH(+

):92

.5%;Q-PCR(+

):>10

0%

1746

,XY

[20];FISH(−

)46

,XY

[20]

1.Initial:48

,XY,+

5,t(9;22

)(q3

4;q1

1.2),+

10,−

21,+

der(22

)t(9;22)

[3]/49

,XY,+

5,t(9;22

),−21

,+der(22

)t(9;22),+

2mar

[1]/46

,XY

[2];FISH(+

):22

.5%;Q-PCR(+

):61

.55%

;

2.CR,10wkafterPh,9wkafterBosutinib:46

,XY

[20];FISH(-);Q-PCR(-)

1846

,XX

[18]

45,XX,−

7[20];Q-PCR(+

)(relapsed/persistent

B-A

LL,6wkbefore

Ph,

low

quality

RNA)

1.Initial

(63%

blasts):45

,XX,−

7[4]/45

,XX,−

7,del(18

)(q2

1)[8]/46

,XX,del

(1)(p1

3),del(4)(p1

5.2),del(5)(q1

3),−

9,t(9;22

)(q3

4;q1

1.2),−

18,+

2mar

[1]/46

,XX

[2]

2.PersistentB-A

LL,3wkafterPh,

before

imatinib:FISH(+

):65

.5%,Q-

PCR(+

):67

.8%

3.t-AML,14

wkafterPh,

9wkafterim

atinib:46

,XX

[30];FISH(-)

1968

~87[3n

],XXX,+

1,+2,+3×

2,+3q

21,+

4,+5,+5q

13,+

9,+9q

10x2

,+10

,+12

,+12

p11.2,+13

,+14

,−16

,−17

,−18

,+19

,+19

p13.1,+20

,+20

q13.3×

2,+22×2,+6m

ar[5]/46

,XX

[15]

74~8

4<4n>,XXX,add

(X)(p2

1),−

1,del(1)

(p21

p36.1),−

2,add(11

)(q2

3),−

13,−

14,−

15,

−17

,der(18

)t(17;18

)(q1

1.2;q1

1.3)x2

,add

(19)

(p13

.3),−22

,+6~

9mar[cp2

]/46

,XX

[18]

Initial:78

~84<

4n>,XXX,add

(X)(p2

1)x2

,−1,der(1)t(1;9)(p13

;q34

),−2,add(2)

(p12

),−4,−5,−9,add(9)(q22

)x2,−10

,−10

,−11

,add

(11)(q23

),−13

,−15

,−16

,−17

,−17

,der(18)t(17

;18)(q11

.2;q11

.3)x2,

add(19

)(p1

3.3),add

(21)(p11

.2)x2,

der(22

)add

(22)(p11

.2)t(9;22)(q34

;q11

.2),−22

,−22

,+ider(?)(?q10

)t(9;22)

(q34

;q11

.2)x2,+2m

ar[cp1

2]/46,XX

[8];FISH(+

):84

.5%;Q-PCR(+

):68

.41%

PhPhiladelphiachromosom

e,FISH

fluo

rescence

insitu

hybridization,

Q-PCRreversetranscriptionqu

antitativepo

lymerasechainreactio

n,NAno

tavailable,

wkweeks,AMLacutemyeloid

leuk

emia,B-ALLBlymph

oblastic

leuk

emia,t-AMLtherapy-relatedAML,PRpartialrespon

se,CRcompleteremission

a Onlykaryotyp

esat

initial

diagno

sisareprov

ided;FISH

orQ-PCR

may

beperformed

later

b Postbo

nemarrow

transplantation

H. Kurt et al.

leukemia resulting from treatment of B lymphoblastic leu-kemia with secondary Philadelphia chromosome.

Treatment and outcome

Before the emergence of secondary Philadelphia chromo-some, all 19 patients received chemotherapy (Table 1). Inaddition, five patients received allogeneic hematopoieticstem cell transplantation. Only nine patients achievedmorphologic remission or deeper response, and all ninepatients developed relapsed disease.

After the emergence of secondary Philadelphia chromo-some, 15 patients had treatment and follow-up informationavailable; the remaining four patients were transferred toother institutions for treatment and were lost to follow-up(Table 1). Seven patients were treated with chemotherapyonly, five treated with chemotherapy plus tyrosine kinaseinhibitors, two treated with tyrosine kinase inhibitors only,and one not treated due to other comorbid conditions.

Thirteen patients died with refractory disease after a medianfollow-up of 3 months (range, 1–9 months) after theemergence of secondary Philadelphia chromosome. Twopatients were living; one (#11) had an initial diagnosis ofacute myeloid leukemia, and had refractory disease at lastfollow-up 8 months after the emergence of secondary Phi-ladelphia chromosome. The other patient (#17) had aninitial diagnosis of B lymphoblastic leukemia, and receivedchemotherapy combined with tyrosine kinase inhibitors, aswell as subsequent allogeneic hematopoietic stem celltransplantation after the emergence of second Philadelphiachromosome. The patient was free of residual disease at lastfollow-up 6 months after the emergence of secondary Phi-ladelphia chromosome. Another patient (#18) with an initialdiagnosis of B lymphoblastic leukemia achieved remissionwith tyrosine kinase inhibitors after the emergence of sec-ondary Philadelphia chromosome. However, this patientdeveloped therapy-related acute myeloid leukemia and diedshortly thereafter.

Table 3 Mutations detected before and at/after emergence of Philadelphia chromosome

No. Mutations before emergence of Ph Mutations at/after emergence of Ph

1 NRAS(+), KRAS(−) FLT3-ITD(−), FLT3 D835(−) FLT3-ITD(−), FLT3 D835(−)

2 FLT3-ITD(+), FLT3 D835(−), CEBPA(+), IDH1(−),IDH2(−), KIT(−), RAS(−) NPM1(−)

FLT3 ITD(+), FLT3 D835(−), ABL1(−)

3 NA FLT3 ITD(+), NRAS(+)a, RUNX1(+)a,WT1(+)a, ABL1(−)

4 NPM1(+), IDH1(+), JAK2(−), KIT(−), FLT3(−), IDH2(−), KRAS(−), NRAS(−)

NPM1(+), IDH1(−), IDH2(−), FLT3(−),KIT(−), CEBPA(−)

5 NRAS(+) NA

6 NRAS(+)a GATA2(+)a NRAS(+)

7 NA ABL1(+), NRAS(−), KIT(−), NPM1(−),CEBPA(−)

8 FLT3-ITD(−), FLT3 D835(−), KRAS(−), NRAS (−) NA

9 NRAS(−), KRAS(−) NA

10 FLT3-ITD (+) FLT3 D835(−), NPM1 (+) FLT3-ITD(+), FLT3 D835(−)

11 Negativea FLT3-ITD(−), FLT3 D835(−)

12 FLT3-ITD(−), FLT3 D835(−), KIT(−), NPM1(−), RAS(−), CEBPA(−), IDH1(−), IDH2(−)

NA

13 FLT3-ITD(−), FLT3 D835(−), KIT(−), NPM1(−), RAS(−)

NA

14 NA JAK2(+)b, EZH2(+)b, CEBPA(+)b

15 FLT3-ITD(−), FLT3 D835(−), RAS(−) NA

16 FLT3-ITD(−), FLT3 D835(−), RAS(−) ABL1(−)

17 NA Negativea, ABL1(−)

18 NA NA

19 NA TP53(+)a

Ph Philadelphia chromosome, NA not available. Common mutations before and at/after emergence of Ph are underlinedaTested with next-generation sequencing-based analysis with 28 gene panelbTested with next generation sequencing-based analysis with 53 gene panel

Secondary Philadelphia chromosome acquired during therapy

Discussion

We reported 19 patients with Philadelphia chromosome-negative de novo acute myeloid leukemia, myelodysplasticsyndrome, B lymphoblastic leukemia, and T lymphoblasticleukemia who secondarily acquired the Philadelphia chro-mosome during therapy. The emergence of secondary Phi-ladelphia chromosome-positive clones by karyotypingoccurred concomitantly with relapsed or refractory diseasein de novo acute leukemia or secondary acute myeloidleukemia arising from myelodysplastic syndrome. In mostpatients, the BCR-ABL1 transcript subtype was of the e1a2(encoding P190 BCR-ABLl protein), and the Philadelphiachromosome-positive disease and the original leukemiawere clonally related. The Philadelphia chromosome-positive clones were the dominant clones in more thanhalf of the patients when secondary Philadelphia chromo-some emerged. Despite the absence of the Philadelphiachromosome-positive clones by karyotyping in 6 patients,13 of 15 patients with follow-up information died withrefractory disease after a median follow-up of 3 months,including one patient with therapy-related acute myeloidleukemia.

Secondary Philadelphia chromosome acquired duringtherapy of myeloid or lymphoid neoplasms is rare; 36 suchcases have been reported in the form of single-case reportsin the English literature (Table 4 and Supplemental Table 2)[20–53]. We reviewed these published cases and reclassi-fied them, if necessary or possible, according to the 2016update of World Health Organization classification [63].The 36 cases included the following: acute myeloid leuke-mia (n= 14), myelodysplastic syndrome (n= 10), B lym-phoblastic leukemia (n= 6), T lymphoblastic leukemia (n= 5), and chronic myelomonocytic leukemia (n= 1). Therewere 20 men and 16 women with a median age of 43 years(range, 3–71 years), approximately 10 years younger thanthat in our study. Similar to our cases, secondary Phila-delphia chromosome was detected at relapse or at a terminalstage of refractory disease in patients with acute leukemia.In patients with myelodysplastic syndrome, the Philadelphiachromosome emerged at time of or after acute transforma-tion in 8 of 10 patients. The median interval from initialdiagnosis to secondary acquisition of the Philadelphiachromosome was 15 months (range, 1–120 months).Twenty-one patients had an abnormal karyotype at initialdiagnosis or anytime during therapy before secondary Phi-ladelphia chromosome emerged; the abnormalities presentbefore the emergence of secondary Philadelphia chromo-some were also observed in the Philadelphia chromosome-positive clones in 19 patients, including one patient withNRAS mutation observed before and at emergence of thePhiladelphia chromosome. Additionally, one patient with anormal karyotype before secondary acquisition of the

Philadelphia chromosome had NPM1 mutations before andat emergence of the Philadelphia chromosome. The BCR-ABL1 fusion transcript encoded P190 in 16/24, P210 in 5/24, and both P210 and P190 both in three patients. Of note,in the latter three patients, the Philadelphia chromosomewas not detected by karyotyping but P210-encoding tran-scripts were detected by reverse transcription-quantitativePCR, and P190/e1a2 transcripts emerged later 3, 4, and14 months before the detection of the Philadelphia chro-mosome by karyotyping, suggesting that the secondaryPhiladelphia chromosome encoded P190. BCR-ABL1 at theonset of the disease was detected in only 2 of 17 patientstested with reverse transcription-quantitative PCR, FISH, orboth. Twenty-three patients had treatment information

Table 4 Summary of clinicopathologic characteristics of patients withsecondary Philadelphia chromosome

Currentstudy

Previous studies[20–53]

Overall

Case number 19 36 55

Age: median; range(yrs)

53 (18–78) 43 (3–71) 48 (3–78)

Interval: median;range (mo)

18 (6–72) 15 (1–120) 16 (1–120)

Disease distribution (n)

AML 11 14 25 (45.5%)

MDS 5 10 15 (27.3%)

B-ALL 2 6 8 (14.5%)

T-ALL 1 5 6 (10.9%)

CMML 0 1 1 (1.8%)

BCR-ABL1 subtype

P190 12/14 16/24 28/38(73.7%)

P210 2/14 5/24 7/38(18.4%)

P190, P210 0 3/24 3/38 (7.9%)

Clonal relatednessa

By karyotype 7/9 19/21 26/30(86.7%)

By molecularmutation

4/5 2/2b 5/6 (83.3%)b

Total 11/14 20/22b 31/36(86.1%)

Median OS after Ph(mo)

3.1 4.5 4

Ph Philadelphia chromosome, Age age at initial diagnosis, yrs years,Interval interval time from initial; diagnosis to the emergence of Ph,mo months, n numberaComparison between diseases at any time before the emergence of Phand at the emergence of PhbIncluding 1 patient with clonally related diseases before and at theemergence of Ph by karyotyping

H. Kurt et al.

available, 21 patients received chemotherapy, 8 receivedtyrosine kinase inhibitors, and 6 received allogeneichematopoietic stem cell transplantation. Of 33 patients withfollow-up information available regarding the disease sta-tus, 30 had relapsed or refractory disease and 26 were deadat last follow-up, with a median follow-up of 5 months(range, 1–22 months). For the 16 patients with follow-upinformation available regarding the evolution of the Phila-delphia chromosome-positive clones, the Philadelphiachromosome-positive clones were persistent and/or becamethe major clone in most patients despite intensive che-motherapy, and only 3 patients achieved cytogeneticremission [32, 52, 53].

The emergence of secondary Philadelphia chromosomecan be explained by multiple mechanisms. It may indicateclonal evolution and disease progression. This hypothesis issupported by the findings that the diseases before and afterthe emergence of secondary Philadelphia chromosome wereclonally related by karyotyping or molecular analyses in thevast majority of patients (86%) in our series and in patientsreported previously (Table 4 and Supplemental Table 2).This apparently underestimates the clonal relatedness giventhe limited panel used to detect molecular mutations.Alternatively, in a subset of patients the emergence ofsecondary Philadelphia chromosome could be due to theexpansion of a minute Philadelphia chromosome-positivesubclone not detectable initially by cytogenetic methods.The detection of the same transcript subtype of e1a2 beforeand at time of emergence of the Philadelphia chromosome-positive subclones in three patients (#1, 11, and 18) in thisstudy would substantiate this theory. In all three patients,interestingly, the Philadelphia chromosome-positive sub-clones clonally related to the previous disease before theemergence of secondary Philadelphia chromosome.

The persistence or refractoriness of disease despite thedisappearance of secondary Philadelphia chromosome-positive clones in some patients suggests that BCR-ABL1is not essential for the maintenance of the leukemic process.However, the persistence of Philadelphia chromosome-positive clones despite chemotherapy and/or tyrosine kinaseinhibitors in some patients and predilection of the e1a2(P190) subtype rather than the typical b2a2/b3a2 (P210) inmost patients support a role of BCR-ABL1 in disease pro-gression. Both P210 and P190 BCR-ABL1 fusion transcriptsresult in new chimeric proteins with increased tyrosinekinase activity. However, P190 was shown to have at leastfivefold higher tyrosine kinase activity than P210 in amurine model [64]. Transgenic mice bearing the e1a2(P190) fusion transcript develop acute leukemia [65],whereas transgenic mice bearing P210 develop chronicmyeloid leukemia [66]. Patients with myelodysplastic syn-drome with P190 at initial presentation show rapid pro-gression to acute myeloid leukemia [67]. P190 is also

associated with transformation of chronic myeloid leukemiato a more aggressive terminal phase disease [68]. In addi-tion, patients with de novo acute myeloid leukemia withP190 have a higher rate of relapse than patients with P210[19]. Overall, these findings correlate with our finding thatP190 is highly associated with disease progression inmyeloid and lymphoid neoplasms.

Adding tyrosine kinase inhibitors to the therapeuticregimens has significantly altered the outcome of patientswith chronic myeloid leukemia [69, 70] and Philadelphiachromosome-positive acute lymphoblastic leukemia [71,72], and the efficacy has also been shown in Philadelphiachromosome-positive de novo acute myeloid leukemia [19].It is worth mentioning that tyrosine kinase inhibitors areeffective in rare cases of myelodysplastic syndrome with thePhiladelphia chromosome [73] and rare cases with con-current BCR-ABL1 and CBFB rearrangements [31, 74, 75].However, the effect of tyrosine kinase inhibitors along withor in place of chemotherapy in patients with late-acquiredPhiladelphia chromosome in relapsed or refractory diseaseis not well understood. We reported seven such patientstreated with tyrosine kinase inhibitors. In this study, eradi-cation of the Philadelphia chromosome-positive clonesdetected by FISH analysis was observed in five of sixpatients with follow-up information although four of themhad refractory Philadelphia chromosome-negative disease.Eight such patients reported in the literature received tyr-osine kinase inhibitors; seven showed partial or completeresponse to tyrosine kinase inhibitors although four patientshad relapsed or refractory disease at last follow-up. Thesefindings show that incorporating tyrosine kinase inhibitorsin the treatment is an effective approach to treat the Phila-delphia chromosome-positive clones in most patients.Overall however, prognosis of these patients is still poordue to other factors.

In conclusion, the Philadelphia chromosome, usuallyseen as a primary change in chronic myeloid leukemia, canalso occur secondarily as a late-developing chromosomalabnormality during therapy of myeloid and lymphoid neo-plasms. The transcript subtype associated with the late-occurring Philadelphia chromosome is overwhelmingly ofthe e1a2 (P190), and the disease before and after theemergence of the Philadelphia chromosome are clonallyrelated. Incorporating tyrosine kinase inhibitors into treat-ment may eradicate the Philadelphia chromosome-positiveclones and could potentially change the disease prognosis ina small subset of patients, but most patients do not respondto the treatment and the overall survival is poor.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict ofinterest.

Secondary Philadelphia chromosome acquired during therapy

References

1. Vardiman JW, Melo JV, Baccarani M, et al. Chronic myelogenousleukaemia, BCR-ABL1 positive, In: Swerdlow SH, Campo E,Harris NL, et al., editors. WHO classification of tumours of hae-matopoietic and lymphoid tissues. IARC: Lyon; 2008. p. 32–37.

2. Borowitz MJ, Chan, JKC. B-lymphoblasticleukemia/lymphomawith recurrent genetic abnormalities. In: Swerdlow SH CE, HarrisNL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman, JW, editors.WHO classification of tumours of haematopoietic and lymphoidtissues. IARC: Lyon; 2008. p. 5.

3. Konoplev S, Yin CC, Kornblau SM, et al. Molecular character-ization of de novo Philadelphia chromosome-positive acutemyeloid leukemia. Leuk Lymphoma. 2013;54:138–44.

4. Nacheva EP, Grace CD, Brazma D, et al. Does BCR/ABL1positive acute myeloid leukaemia exist? Br J Haematol.2013;161:541–50.

5. Soupir CP, Vergilio JA, Dal Cin P, et al. Philadelphiachromosome-positive acute myeloid leukemia: a rare aggressiveleukemia with clinicopathologic features distinct from chronicmyeloid leukemia in myeloid blast crisis. Am J Clin Pathol.2007;127:642–50.

6. Carbonell F, Swansbury J, Min T, et al. Cytogenetic findings inacute biphenotypic leukaemia. Leukemia. 1996;10:1283–7.

7. Killick S, Matutes E, Powles RL, et al. Outcome of biphenotypicacute leukemia. Haematologica. 1999;84:699–706.

8. Raanani P, Trakhtenbrot L, Rechavi G, et al. Philadelphia-chromosome-positive T-lymphoblastic leukemia: acute leukemiaor chronic myelogenous leukemia blastic crisis. Acta Haematol.2005;113:181–9.

9. You MJ, Medeiros LJ, Hsi ED. T-lymphoblastic leukemia/lym-phoma. Am J Clin Pathol. 2015;144:411–22.

10. Melo JV, Myint H, Galton DA, et al. P190BCR-ABL chronicmyeloid leukaemia: the missing link with chronic myelomono-cytic leukaemia? Leukemia. 1994;8:208–11.

11. Gong Z, Medeiros LJ, Cortes JE, et al. Clinical and prognosticsignificance of e1a2 BCR-ABL1 transcript subtype in chronicmyeloid leukemia. Blood Cancer J. 2017;7:e583.

12. Melo JV. The diversity of BCR-ABL fusion proteinsand their relationship to leukemia phenotype. Blood.1996;88:2375–84.

13. Pane F, Frigeri F, Sindona M, et al. Neutrophilic-chronic myeloidleukemia: a distinct disease with a specific molecular marker(BCR/ABL with C3/A2 junction). Blood. 1996;88:2410–4.

14. Arora A, Scholar EM. Role of tyrosine kinase inhibitors in cancertherapy. J Pharmacol Exp Ther. 2005;315:971–9.

15. Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2016 updateon diagnosis, therapy, and monitoring. Am J Hematol.2016;91:252–65.

16. Wassmann B, Pfeifer H, Goekbuget N, et al. Alternating versusconcurrent schedules of imatinib and chemotherapy as front-linetherapy for Philadelphia-positive acute lymphoblastic leukemia(Ph + ALL). Blood. 2006;108:1469–77.

17. Fielding AK, Rowe JM, Buck G, et al. UKALLXII/ECOG2993:addition of imatinib to a standard treatment regimen enhanceslong-term outcomes in Philadelphia positive acute lymphoblasticleukemia. Blood. 2014;123:843–50.

18. Fielding AK. Treatment of Philadelphia chromosome-positiveacute lymphoblastic leukemia in adults: a broader range ofoptions, improved outcomes, and more therapeutic dilemmas. AmSoc Clin Oncol Educ Book. 2015:e352–e359.

19. Reboursiere E, Chantepie S, Gac AC, et al. Rare but authenticPhiladelphia-positive acute myeloblastic leukemia: two casereports and a literature review of characteristics, treatment andoutcome. Hematol Oncol Stem Cell Ther. 2015;8:28–33.

20. Kohn G, Manny N, Eldor A, et al. De novo appearance of the ph-1chromosome in a previously monosomic bone marrow (45,XX,-6): conversion of a myeloproliferative disorder to acute myelo-genous leukemia. Blood. 1975;45:653–7.

21. Abe S, Sandberg AA. Chromosomes and causation of humancancer and leukemia. XXXII. Unusual features of Ph1-positiveacute myeloblastic leukemia (AML), including a review of theliterature. Cancer. 1979;43:2352–64.

22. Smadja N, Krulik M, De Gramont A, et al. Acquisition of a Phi-ladelphia chromosome concomitant with transformation of arefractory anemia into an acute leukemia. Cancer. 1985;55:1477–81.

23. Jacobsen RJ, Himoe E, Sacher RA, et al. Late appearance ofPhiladelphia chromosome. Br J Haematol. 1986;63:392–4.

24. Vandenberghe E, Martiat P, Baens M, et al. Megakaryoblasticleukemia with an N-ras mutation and late acquisition of a Phila-delphia chromosome. Leukemia. 1991;5:683–6.

25. Shimamoto T, Ohyashiki K, Ohyashiki JH, et al. Late appearanceof a Philadelphia translocation with minor-BCR/ABL transcript ina t(7;11)(p15; p15) acute myeloid leukemia. Leukemia.1995;9:640–2.

26. Fujimura T, Ohyashiki K, Ohyashiki JH, et al. Two additionalcases of acute myeloid leukemia with t(7;11)(p15; p15) havinglow neutrophil alkaline phosphatase scores. Cancer Genet Cyto-genet. 1993;68:143–6.

27. Matsue K, Miyamoto T, Ito M, et al. Late appearance of thePhiladelphia chromosome with monosomy 7 in a patient with denovo AML with trilineage myelodysplasia. Am J Hematol.1995;49:341–6.

28. Chen Z, Morgan R, Notohamiprodjo M, et al. The Philadelphiachromosome as a secondary change in leukemia: three casereports and an overview of the literature. Cancer Genet Cytogenet.1998;101:148–51.

29. Najfeld V, Geller M, Troy K, et al. Acquisition of the Ph chro-mosome and BCR-ABL fusion product in AML-M2 and t(8;21)leukemia: cytogenetic and FISH evidence for a late event. Leu-kemia. 1998;12:517–9.

30. Shah N, Leaker MT, Teshima I, et al. Late-appearing Philadelphiachromosome in childhood acute myeloid leukemia. Pediatr BloodCancer. 2008;50:1052–3.

31. Bacher U, Haferlach T, Alpermann T, et al. Subclones with the t(9;22)/BCR-ABL1 rearrangement occur in AML and seem tocooperate with distinct genetic alterations. Br J Haematol.2011;152:713–20.

32. Aoki J, Kakihana K, Kobayashi T, et al. Tyrosine kinase inhibitortherapy for acute myeloid leukemia with late-appearing Phila-delphia chromosome. Leuk Res. 2012;36:e41–e42.

33. Neuendorff NR, Schwarz M, Hemmati P, et al. BCR-ABL1(+)acute myeloid leukemia: clonal selection of a BCR-ABL1(-)subclone as a cause of refractory disease with nilotinib treatment.Acta Haematol. 2015;133:237–41.

34. Verhoef G, Meeus P, Stul M, et al. Cytogenetic and molecularstudies of the Philadelphia translocation in myelodysplastic syn-dromes. Report of two cases and review of the literature. CancerGenet Cytogenet. 1992;59:161–6.

35. Kohno T, Amenomori T, Atogami S, et al. Progression frommyelodysplastic syndrome to acute lymphoblastic leukaemia withPhiladelphia chromosome and p190 BCR-ABL transcript. Br JHaematol. 1996;93:389–91.

36. Roumier C, Daudignon A, Soenen V, et al. p190 bcr-abl rear-rangement: a secondary cytogenetic event in some chronic mye-loid disorders? Haematologica. 1999;84:1075–80.

37. Kelemen K, Galani K, Conley CR, et al. Secondary Philadelphiachromosome and erythrophagocytosis in a relapsed acute myeloidleukemia after hematopoietic cell transplantation. Cancer Genet.2014;207:268–71.

H. Kurt et al.

38. Yamashita S, Umemura T, Sadamura S, et al. Acute leukemiasexpressing p210-and p 190-type bcr/abl mRNAs: report of twocases and review of the literature. Acta Haematol.1996;96:99–104.

39. Nakamura K, Inaba T, Nishimura J, et al. Molecular analysis ofBCR/ABL products in a case of myelodysplastic syndrome withlate appearing Philadelphia chromosome. Br J Haematol.1991;78:130–2.

40. Katsuno M, Yamashita S, Sadamura S, et al. Late-appearingPhiladelphia chromosome in a patient with acute nonlymphocyticleukaemia derived from myelodysplastic syndrome: detection ofP210- and P190-type bcr/abl fusion gene transcripts at the leu-kaemic stage. Br J Haematol. 1994;87:51–56.

41. Keung YK, Beaty M, Powell BL, et al. Philadelphia chromosomepositive myelodysplastic syndrome and acute myeloid leukemia-retrospective study and review of literature. Leuk Res.2004;28:579–86.

42. Prebet T, Michallet AS, Charrin C, et al. Secondary Philadelphiachromosome after non-myeloablative peripheral blood stem celltransplantation for a myelodysplastic syndrome in transformation.Bone Marrow Transplant. 2004;33:247–9.

43. Hamaguchi H, Suzukawa K, Nagata K, et al. Establishment of anovel human myeloid leukaemia cell line (HNT-34) with t(3;3)(q21; q26), t(9;22)(q34;q11) and the expression of EVI1 gene,P210 and P190 BCR/ABL chimaeric transcripts from a patientwith AML after MDS with 3q21q26 syndrome. Br J Haematol.1997;98:399–407.

44. Miller BA, Reid MM, Nell M, et al. T-cell acute lymphoblasticleukaemia with late developing Philadelphia chromosome. Br JHaematol. 1984;56:139–46.

45. Coad JE, Arthur DC, Gajl-Peczalska KJ, et al. Late-developingPhiladelphia chromosomes in a case of T-cell acute lymphoblasticleukemia. Leukemia. 1994;8:889–94.

46. Tsuchiya H, Migita M, Yamamori S, et al. A late-appearingPhiladelphia chromosome in acute lymphoblastic leukemia con-firmed by expression of BCR-ABL mRNA. Leukemia.1995;9:1689–93.

47. Tchirkov A, Bons JM, Chassagne J, et al. Molecular detection of alate-appearing BCR-ABL gene in a child with T-cell acute lym-phoblastic leukemia. Ann Hematol. 1998;77:55–59.

48. Campbell LJ, Martinow A, Michael PM, et al. Correlation ofcytogenetics, BCR-ABL PCR studies and fluorescence in situhybridisation (FISH) in adult acute lymphoblastic leukaemia. AustN Z J Med. 1999;29:707–12.

49. Sessarego M, Defferrari R, Dejana A, et al. Late-appearing Phi-ladelphia chromosome in acute lymphoblastic leukemia. CancerGenet Cytogenet. 1990;48:35–38.

50. Inokuchi K, Shinohara T, Futaki M, et al. Establishment ofa cell line with variant BCR/ABL breakpoint expressingP180BCR/ABL from late-appearing Philadelphia-positive acutebiphenotypic leukemia. Genes Chromosomes Cancer.1998;23:227–38.

51. Chen L, Stamatoullas A, Bastard C, et al. Secondary Philadelphiachromosome in a patient with acute lymphoblastic leukemia.Cancer Genet Cytogenet. 2004;152:132–5.

52. Hato A, Murayama T, Nishikawa S, et al. Philadelphia chromo-some positive acute lymphoblastic leukemia showing normalkaryotype in G-banding chromosomal examination before che-motherapy. Hematology. 2005;10:379–81.

53. Adriana Z, Al Bahar S, Pandita R. Acute lymphoblastic leukemiawith a late- appearing Philadelphia chromosome: case report andreview of the literature. Gulf J Oncol. 2013;1:81–86.

54. Simons A, Shaffer LG, Hastings RJ. Cytogenetic nomenclature:changes in the ISCN 2013 compared to the 2009 edition. Cyto-genet Genome Res. 2013;141:1–6.

55. Merzianu M, Medeiros LJ, Cortes J, et al. inv(16)(p13q22) inchronic myelogenous leukemia in blast phase: a clinicopathologic,cytogenetic, and molecular study of five cases. Am J Clin Pathol.2005;124:807–14.

56. Luthra R, Medeiros LJ. TaqMan reverse transcriptase-polymerasechain reaction coupled with capillary electrophoresis for quanti-fication and identification of bcr-abl transcript type. Methods MolBiol. 2006;335:135–45.

57. Gabert J, Beillard E, van der Velden VH, et al. Standardizationand quality control studies of ‘real-time’ quantitative reversetranscriptase polymerase chain reaction of fusion gene transcriptsfor residual disease detection in leukemia—a Europe AgainstCancer program. Leukemia. 2003;17:2318–57.

58. Luthra R, Patel KP, Reddy NG, et al. Next-generation sequencing-based multigene mutational screening for acute myeloid leukemiausing MiSeq: applicability for diagnostics and disease monitoring.Haematologica. 2014;99:465–73.

59. Ok CY, Patel KP, Garcia-Manero G, et al. Mutational profiling oftherapy-related myelodysplastic syndromes and acute myeloidleukemia by next generation sequencing, a comparison with denovo diseases. Leuk Res. 2015;39:348–54.

60. Warren M, Luthra R, Yin CC, et al. Clinical impact of change ofFLT3 mutation status in acute myeloid leukemia patients. ModPathol. 2012;25:1405–12.

61. Patel KP, Barkoh BA, Chen Z, et al. Diagnostic testing for IDH1and IDH2 variants in acute myeloid leukemia an algorithmicapproach using high-resolution melting curve analysis. J MolDiagn. 2011;13:678–86.

62. Bai S, Hu S. BCR-ABL1-negative acute myeloid leukaemiarelapsing as BCR-ABL1-positive disease. Br J Haematol.2017;176:514.

63. Arber DA, Orazi A, Hasserjian R, et al. The2016 revision to theWorld Health Organization classification of myeloid neoplasmsand acute leukemia. Blood. 2016;127:2391–405.

64. Ghaffari S, Daley GQ, Lodish HF. Growth factor independenceand BCR/ABL transformation: promise and pitfalls of murinemodel systems and assays. Leukemia. 1999;13:1200–6.

65. Voncken JW, Griffiths S, Greaves MF, et al. Restricted onco-genicity of BCR/ABL p190 in transgenic mice. Cancer Res.1992;52:4534–9.

66. Daley GQ, Van Etten RA, Baltimore D. Inductionof chronic myelogenous leukemia in mice by theP210bcr/abl gene of the Philadelphia chromosome. Science.1990;247:824–30.

67. Lesesve JF, Troussard X, Bastard C, et al. p190bcr/abl rearran-gement in myelodysplastic syndromes: two reports and review ofthe literature. Br J Haematol. 1996;95:372–5.

68. Dhingra K, Talpaz M, Kantarjian H, et al. Appearance of acuteleukemia-associated P190BCR-ABL in chronic myelogenousleukemia may correlate with disease progression. Leukemia.1991;5:191–5.

69. Kantarjian H, Sawyers C, Hochhaus A, et al. Hematologic andcytogenetic responses to imatinib mesylate in chronic myelogen-ous leukemia. N Engl J Med. 2002;346:645–52.

70. Sawyers CL, Hochhaus A, Feldman E, et al. Imatinib induceshematologic and cytogenetic responses in patients with chronicmyelogenous leukemia in myeloid blast crisis: results of a phase IIstudy. Blood. 2002;99:3530–9.

71. Druker BJ, Sawyers CL, Kantarjian H, et al. Activity of a specificinhibitor of the BCR-ABL tyrosine kinase in the blast crisis ofchronic myeloid leukemia and acute lymphoblastic leukemiawith the Philadelphia chromosome. N Engl J Med.2001;344:1038–42.

72. Ottmann OG, Druker BJ, Sawyers CL, et al. A phase 2 study ofimatinib in patients with relapsed or refractory Philadelphia

Secondary Philadelphia chromosome acquired during therapy

chromosome-positive acute lymphoid leukemias. Blood.2002;100:1965–71.

73. Drummond MW, Lush CJ, Vickers MA, et al. Imatinibmesylate-induced molecular remission of Philadelphiachromosome-positive myelodysplastic syndrome. Leukemia.2003;17:463–5.

74. Dai HP, Xue YQ, Wu LL, et al. p210 BCR/ABL1 as a secondarychange in a patient with acute myelomonocytic leukemia (M4Eo)with inv(16). Int J Hematol. 2012;96:814–7.

75. Salem A, Loghavi S, Tang G, et al. Myeloid neoplasms with con-current BCR-ABL1 and CBFB rearrangements: a series of 10 cases ofa clinically aggressive neoplasm. Am J Hematol. 2017;92:520–8.

H. Kurt et al.

Supplemental Table 1. Complete blood count and differential count at time of Philadelphia chromosome emergence

No. Initial Dx

Hgb (g/dl)

PLT (K/μl)

WBC (K/ μl)

Neutrophil (%)

Immature Granulocyte (%)

Lymphocyte (%)

Monocyte (%)

Eosinophil (%)

Basophil (%)

Blast (%)

1 AML 14.6 210 8.2 39 3 18 23 1 0 16

2 AML 10.1 19 2.5 11 0 76 1 11 1 0

3 AML 8.8 43 53.4 10 2 2 14 0 1 71

4 AML 11.5 226 9 66.3 1.6 15.5 14.9 1.1 0.6 0

5 AML 8.4 62 2.7 22 0 52 13 2 3 8

6 AML 9.7 20 25.7 44 3 9 2 0 0 42

7 AML 9.8 55 37.7 1 0 1 1 0 1 96

8 AML 8.8 19 8 2 2 24 6 0 0 66

9 AML 10.6 16 31.7 9 23 4 0 0 0 64

10 AML 8.9 15 2.1 68.9 3.4 13.6 12.6 1.5 0 0

11 AML 9.6 104 13.9 3 0 24 7 1 0 65

12 MDS 9.7 23 3.8 28 0 58 1 1 0 12

13 MDS 8.9 202 89.2 29 8 13 18 7 2 23

14 MDS 9.9 57 2.4 79 2 10 9 0 0 0

15 MDS 9.0 12 1.0 6 3 78 9 0 2 2

16 MDS 11.4 27 28.1 2 0 3 8 0 0 87

17 B-ALL 9.5 36 1.2 29 0 66 0 0 0 5

18 B-ALL 9.1 8 3.6 4 0 66 2 4 0 24

19 T-ALL 10.3 29 27.9 55 3 2 2 1 1 36

Abbreviations: Ph, Philadelphia chromosome; Dx, diagnosis; Hgb, hemoglobin; PLT, platelet; WBC, white blood cell; AML, acute myeloid leukemia; MDS, myelodysplastic syndrome; B-ALL, B -lymphoblastic leukemia; T-ALL, T -lymphoblastic leukemia.

Supplemental Table 2. Clinical, cytogenetic/FISH and molecular features of published cases with secondary Philadelphia chromosome

Ref Age/ sex

Initial dx

Cytogenetic/FISH and molecular data before emergence of Ph

Interval (months) Dx at Ph detection Cytogenetic/FISH and molecular data

at and after emergence of Ph BCR-ABL1 transcript Tx Disease status, outcome,

survival after Ph

Kohn19 38/F AML 1) Onset: NA 2) stable (4 mo): 45,XX,-6 [30] 7 Refractory AML 1) Initial: 45,XX,-6[20]/45,XX,-6,-22,+Ph1[2]

2) 2 wk after Ph: 45,XX,-6,-22,+Ph1[22] NA Chemo Refractory, AML, died, 2 mo

Abe20 33/F AML 1) Onset: 46,XX[18] 2) 1st relapse (11 mo): 46,XX[4] 12 Relapsed / persistent

AML Initial: t(9;22)(q34;q11)[7] NA Chemo Relapsed/ persistent AML, died, 14 mo

Abe20 40/M AML Onset: 46,XY[44] 1 Persistent AML

1) Initial (8% blasts): t(9;22)(q34;q11)[37] 2) 1 wk after Ph (52% blasts): t(9;22)(q34;q11)[14] 3) 4 wk after Ph (11% blasts): No Ph 4) 7 wk after Ph (52% blasts): No Ph 4) 13 wk after Ph (96% blasts): No Ph

NA NA Refractory AML, died, 5 mo

Smadja21 62/M AML 1) Onset: NA 2) stable disease (6 mo): 46, XY[19] 17 Progression of AML

1) Initial: 46.XY,Ph' (100%)[33/33] 2) PR (22 mo): 46,XY,Ph' (60%)4 6.XY (30%)/4 7,XY,+11 (10%) 3) PR (32 mo): 46,XY,Ph' (26%)/ 46,XY (38%)/ 47,XY,+ 11 (36%) 4) Refractory (35 mo): 46,XY,Ph' (100%)

NA Chemo Persistent/refractory AML, died, 21 mo

Jacobsen22 62/F AML 1) Onset: 46,XX[49] 2) CR (2 mo): 46,XX 3) 1st relapse (32 mo): NA

40 2nd relapse 1) Initial: 46, XX[17]/46, XX,t(9;22)(q34;q11)[12 ] 2) persistent AML (1 mo after chemo):46,XX[20] NA Chemo Refractory; died; shortly

after

Vandenberghe23 28/F AML

1) Onset: 45,XX-7,ins(12;3)(q14;q22q27); Q-PCR (-), NRAS (+) 2) post-alloSCT (3 mo): 46, XY[10] 3) 1st relapse (8 mo): NA; NRAS (+) 4)PR (10 mo): NA; NRAS (+)

13 Refractory Initial: 45,XX-7,ins(12;3)(q14;q22q27)[3]/45,XX-7,t(9;22)(q34;q11),ins(12;3)(q14;q22q27)[7]; NRAS (+) p190 NA Persistent AML, died, NA

(shortly after)

Shimamoto 24 Fujimura25 58/F AML

1) Onset: 46, XX,t(7;11)(p15;p15)[10]; Q-PCR (-) 2) PR (5 mo): 46,XX[17]46, XX,t(7;11)(p15;p15)[3] 3) Refractory (8 mo): 46, XX,t(7;11)(p15;p15)[19]/46,idem,t(2;10)(q22;q26)[1]; Q-PCR (-) 4)PR (15 mo): 46, XX[9]/46, XX,t(7;11)(p15;p15)[5]

16 Refractory Initial: 46, XX[3]/46, XX,t(7;11)(p15;p15)[4]/46,idem,t(9;22)(q34;q11)[4]/46,idem, add(12)(p12)[1]

p190 Chemo Persistent/refractory AML, died, 3 mo

Matsue26 63/F AML 1) Onset: 46,XX; Q-PCR (-) 2) 1st relapse (10 mo): 46,XX; Q-PCR (-) 17 Relapsed/ refractory

AML Initial: 45,XX,-7,t(9;22)(q34;q11)[20] p190 Chemo Refractory AML, NA, NA

Chen27 16/M AML Onset: 45,XY,-7,t(10;14)(q11.2;q11.2) [8]/44,XY,add(1)(p36),t(6;6)(p11.2;q13),-7,del(13)(q13),add(14)(p11),-16 [7]/42,XY,add(1)(q44),-4,-5,-7,-8,-9,add(9)(p22),-11,add(14)(q32),-15,-19,-22,+5mar [5]

1 Post-alloSCT

1)initial: 45,XY,-7,t(9;22)(q34;q11.2),t(10;14) [8]/40~45,XY,-7,inc [12]; FISH (+), 83.7% 2)Refractory (3 mo): 45,XY,t(3;17)(q26;q23),-7,t(9;22),t(10;14)[18]/44,XY,-7,inc [2] 3)refractory (7 mo): 45,XY,t(3;17),-7,t(9;22),t(10;14) [20]

p190 NA Refractory, alive, lost in F/U (6 mo)

Najfeld28 62/F AML 1) Onset: 46, XX[8]/45,X,-X,t(8;21)(q22;q22)[20] 2)1st relapse (14mo): 46, XX[33]/46,XX,t(8;21)[2] 18 Relapsed/ persistent

AML

1) Initial: 46,XX[4]/46,XX,del(5)t(8;21)[8]/46,XX,del(5)t(8;21),t(9;22)(q34;q11)[1 ] 2)CR (20 mo): 46,XX 3) 2nd relapse (21 mo): 46,XX[8]/ 46,XX,del(5)t(8;21),t(9;22)[40]/46,X,del(X)(p11p21),del(5),t(8;21),t(9;22)[3]/46,XX,der(1)t(1;7)(p34.2;q22),del(5),del(7)(q22),t(8;21)t(9;22)[4]

p190 chemo Relapsed/ refractory, died, 8 mo

Shah29 3/F AML

1) Onset: 47,XX, +8[16]; FISH (-) 2) 2nd induction (3 mo): 46,XX,t(11;15)(p13;q26),del(20)(q11.2) [9] 3) refractory (12 mo): 46,XX,t(11;15)(p13;q26),del(20)(q11.2)[20]; FISH (+) , 1 metaphase 4) refractory (13 mo): 46,XX,t(11;15)(p13;q26),del(20)(q11.2)[1]; FISH (+) , 4/176

14 Refractory AML

1) Initial: 46,XX,t(9;22)(q34;q11.2)[7]46,XX,t(11;15)(p13;q26),del(20)(q11.2)[5]; FISH (+), 34/200 2) Persistent, 3 wk after Ph: 46,XX,t(9;22)(q34;q11.2)[23]; FISH (+), 125/200

p190 Imatinib Refractory AML, died, 4 mo

Bacher30 71/M AML Onset: 46, XY; NPM1 (+) 22 Relapsed/ refractory AML

1) Initial: 45,XY,der(7;21)dic(7;21)(q21;q22)ins(7;21)(q11;q?q?) [10]/46,XY,t(9;22)(q34;q11)[3]/46,XY[8]; NPM1 (+) 2) refractory: Ph[17/20]; Q-PCR (+), 45%; NPM1 (+)

p190 NA Relapsed/refractory, died, 4 mo

Aoki31 48/F AML 1) Onset: 46, XX, del(7)(q11.2) (18/20) 2) 1st relapse (11 mo): 46,XX 3) 2nd relapse (19 mo), post-AlloSCT: NA

23 Relapsed/ progressive

1) Initial: 46, XX, del (7)(q?),t(9; 22), del(11)(q?) (2/20 cells) 2) CR (chemo + alloSCT): NA 3) 3rd relapse (33 mo): 46, XX, del (7)(q?),t(9; 22), del(11)(q?) (1/20 cells); FISH (+), 5/100

NA

Chemo, alloSCT; chemo, imatinib, dasatinib, nilotinib

CR, died, 22 mo

Neuendorff32 65/M AML 1) Onset: t(6; 11)(q27;q23) (20/20) 2)1st relapse (11 mo): NA, MLL-AF6 Q-PCR (+); BCR-ABL1 Q-PCR (-)

NA 2nd relapse (15 mo after alloSCT)

1) Initial: 46,XY, t(6; 11)(q27;q23), t(9; 22)(q34;q11) [24] /46,XY, t(6; 11)(q27;q23) [1] ; FISH (+), 74%; Q-PCR (+) 2) chemo with no response: NA 3) 1 mo nilotinib, persistent disease: 46,XY, t(6; 11)(q27;q23)(dominant clone)/46,XY, t(6; 11)(q27;q23), del(20q)[1]; FISH (+), 3%

p190 Chemo, nilotinib (1mo)

Relapsed/ refractory; alive, NA

Verhoef33 63/M MDS Onset: 46, XY 18 MDS-EB-2 (18% blasts) Initial: 46,XY,t(9;22)(q34;q11)(100%) NA NA Refractory, alive, 3 mo

Kohno34 54/M MDS 1) Onset: 46,XY[20] 2) MDS EB-1 (24 mo): 46,XY,20q-[20] 30 B-ALL transformation Initial: 46, XY,t(9;22)(q34;q11),20q-[18]/46,XY,20q-[2] p190 Chemo Persistent, NA, NA

Roumier35 53/F MDS 1) Onset: del5q 2) 16 mo before Ph: del5q; FISH (-) 60

CMML-2 (11% blasts) (WBC:22, mono37, eos 4, immature 2, no splenomegaly)

Initial: 44, XX, del(5) (q13q33), add(13)(p11), -17, -18,add(20) (q12), -21, +mar1(4)/ 44-45, idem, (0-1)inv(1) (p11q25), t(9;22)(q34;q11), +(0-1)der(22) t(9;22) (q34;q11)

p190 NA Persistent CMML-1, died, 2 mo

Bacher30 64/F MDS Onset: del5q 120 sAML Initial: 46,XX,del(5)(q14q34),t(9;22)(q34;q11)[11]/45,XX,del(5)(q14q34),t(9;22)(q34;q11),dic(16;17)(q11;p11)[4]/46,XX[5]

p210 Imatinib, dasatinib, alloSCT

Relapsed AML; alive, 15 mo

Kelemen36 66/M MDS 1) Onset: del20q 2) sAML (8 mo): 46,XY,del(7)(q22q34),del(20)(q11.2;q13.1)[16]/46,XY[4]

NA 1st relapse (3 mo after alloSCT)

Initial: 46,XY,del(7)(q22q34),t(9;22)(q34;q11.2),del(20)(q11.2q13.1)[18]/46,idem, t(X;10)(q24;q11.2)[2]--FISH 91%

NA Chemo Relapsed/persistent AML, died, 8 mo after AML transformation

Yamashita37 39/M MDS-EB-1

1) Onset: 46,XY,t(3;3)(q21;q26)[19]/46,XY[1];Q-PCR (-) 2) sAML (3 mo): 46,XY,t(3;3)(q21;q26)[20]; Q-PCR p210 (+) 16 Refractory AML 46,XY,t(3;3)(q21;q26)[50]/46,XY,del(1)(q22),r(3;3)(q21;q26),-

16[6]/46,XY,t(3;3)(q21;q26),t(9;22)(q34;q11)[3] p190 (p210) Chemo Refractory, died, 2 mo

Nakamura38 3/M MDS-EB-2

1) Onset: 46,XY[30]; Q-PCR (-) 2) sAML (23 mo): 46,XY[30] 32 Refractory AML Initial: 46.XY,t(9:22)(q34:q11) p210 NA NA

Katsuno39 39/M MDS-EB-2

1) Onset: 46,XY,t(3;3) (q21;q26)[19]; Q-PCR (-) 2) sAML (3 mo): 46,XY,t(3:3)( q21;q26) [20]; Q-PCR p210 (+) 17 Refractory AML Initial: 46,XY,t(3;3) (q21:q26) (50)/46,XY,del(1)( p22),t(3;3)( q21;q26),-

16[6]/46,XY,t(3;3)( q21:q26),t(9;22(q34:q11)[3] p190, p210 Chemo Persistent AML, died, 14 mo

Keung40 71/M MDS-EB-2 Onset: 46,XY 5 sAML Initial: 46,XY,t(9;22)(q34;q11)[20] NA Chemo Persistent AML, died, 4 mo

Prebet41 48/F MDS-EB-2

1) Onset: +8 (12/20); FISH (-); Q-PCR (-) 2) relapsed s AML (8 mo): +8 12 2nd AML relapse Initial: 46,XX,del(5)(q21q32),t(9;22)(q34;q11),

del(12)(q21q24),del(13)(q13q32),add(15)(q23),add(16)(q13) p190 Chemo, imatinib PR, died, 3 mo

Hamaguchi42 45/F CMML-2

1) Onset: 46,XX,t(3;3)(q21;q26)[20] 2) Persistent sAML (10 mo): NA; Q-PCR p210 (+) 14 Refractory sAML Initial: 46,XX,t(3;3)(q21;q26),t(9;22)(q34;q11)[19] p190, p210 NA Progressive AML, died, 4

mo

Miller43 5/M T-ALL Onset: 46,XY,9p-[19] 4 1st relapse 1) Initial: 46 XY,9p-, 6q-,t(9q+;22q-)[20] 2) PR (8 mo): 46,XY[7]/46 XY,9p, 6q-,t(9q+;22q-)[1] 3) refractory (9 mo): 46 XY,9p, 6q-,t(9q+;22q-)[12]

NA Chemo Progressive ALL, died, 7 mo

Coad44 7/M T-ALL Onset: 46,XY,der7t(7;9)(q3?4;q22),-9,+add(12)(p11q2?2)[21]/46,XY[1] 13 1st relapse Initial: 47,XY,der7t(7;9)(9;22)(q3?4;q22q34;q11),-

9,+der(22)t(9;22)(q34;q11),+mar[13] p210 Chemo, alloSCT

Relapsed ALL, died, 2 wk after 2nd relapse

Tsuchiya45 12/M T-ALL Onset: 46, XY,del(9)(p?22)[3]/46,XY[1]; Q-PCR (-); SB clonal TCR-B (+) 6 1st relapse

Initial: 46, XY,del(9)(p?22),t(9;22)(q34;q11)[1]/46,XY,del(10)(q34),add(13)(p13)[1]/46,XY[18]--same TCRB clone by Southern Blot

p210 Chemo, alloSCT

Persistent ALL, died, shortly after

Tchirkov46 5.5/M T-ALL Onset: 46,XY[26]; Q-PCR (-) 7 1st relapse

1) Initial: NA; FISH (+), 29%; Q-PCR (+), 4% 2) clinical remission: 46, XY[16]; FISH(+), 4.5%; Q-PCR (+) 3)2nd relapse (10 mo): 46, XY[16]; FISHinterphase(+), 25%; FISHmetaphase (+),

4/12; Q-PCR (+), 52% p210 NA Progressive ALL, died,

7 mo

Campbell47 26/M T-ALL Onset: 45,XY,del(6)(q 15q241,der(9)t(9:14)(p 13;q11),-14[14]/46.XY[15]; Q-PCR (+); FISH (+), 25/427(6%) NA 1st relapse

Initial: 45,XY,add(5)(q31),del(6)(q15q25),t(8;14)(q24; q11),der(9)t(9;14)(p13;q11),-14[3]/45, idem,add( 16)(p1 3)[3]/46,XY,del(1 ) (q42),+der(9)t(9;14)(p13;q11)t(9;22)(q34;q11),-14,der( 22)t(9;22)(q34;q 1 1 )[ 1 1]/46, XY [4]

p210 NA NA, NA, 13 mo after diagnosis

Sessarego48 45/F B-ALL 1) Onset: 46, XX[21] 2) 1st relapse (8 mo): 46, XX 13 2nd relapse Initial: 46, XX,t(9;22)(q34;q11)[15]/46,XX[9] NA NA Relapsed/persistent

disease, died, 1 mo

Tsuchiya45 10/M B-ALL 1) Onset: NA, Q-PCR (-); SB clonal IgH (+) 2) 1st relapse (9 mo): 46, XY [20] 16 Relapsed/ persistent

Initial: 44,t(X;11)(p11;p15),-Y, add(3)(q29),der(8)t(1;8)(q21;q24),del(9)(p13), t(9;22)(q34;q11), -12,der(?)t(12;?)(q13;?),-16[6]#SB clonal IgH (+)

p190 NA Persistent disease, died, 2 wk

Inokuchi49 52/F B-ALL Onset: 46,XX[20] 2 Refractory

1) Initial: 46,XX,t(9;22)(q34;q11)[6]/other nonspecific aberration with 46,XX,t(9;22)(q34;q11)[14] 2) 1st relapse (6 mo): 46,XX,t(9;22)(q34;q11),-20,add(21)(q22)[18]# 3) 2nd relapse: 46,XX,der(5)(5pter ok 5q11.2::22q11ok22qter), der(9)(9pterok9q34::5q11.2ok5qter),del(10(q11.2),inv(12)(p13q13), der(22)(22pterok22q11::9q34ok9qter),del(22)(q11)[11]#

p190 NA Relapsed/refractory, died, 8 mo

Chen50 23/F B-ALL 1) Onset: 48,XX,+X, +14[7]/46,XX[10]; Q-PCR (+); SB clonal IgH (+) 2) CR (2 mo): 46,XX[20]; Q-PCR (-)

15 1st relapse

1) Initial: 47,XX,add(9)(p22),+mar[5]/47,XX,add(9)(p22),t(9;22)(q34;q11),+mar[13]; IgH clone (-); Kappa clone (+) 2) CR (chemo,1 mo after Ph): 46,XX[20]; Q-PCR (-) 3) 2nd relapse, after 1 mo imatinib, 2 mo after Ph: 47,XX,add(9)(p22), mar[13]/46,XX[6]; Q-PCR (+) 4) post-alloBMT day 30, 3 mo after Ph: 46,XX[20]; Q-PCR (-) 5) 3rd relapse: 47,XX,add(3)(q21),inv(3)(q21q26),add(4)(q28), add(9)(p22),(9;22)(q34;q11),add(12)(p13),+mar[13]/46,XX[1]; Q-PCR (+); Kappa clone(+)

p190 Chemo, imatinib, alloSCT

Relapsed leukemia, died, 5 mo

Hato51 29/M B-ALL Onset: 46,XY[20]; Q-PCR (+); FISH (+), 12.5% NA CR

1) Initial: t(9;22)(q34;q11)[2/20]; FISH (+), 0.9% 2) after alloSCT: 46,XY; FISH (-); Q-PCR (-) 3) 7 mo after alloSCT: Q-PCR (+) 4) 1st relapse (11 mo after alloSCT): t(9;22)(q34;q11)[10/20]; FISH (+), 39%; Q-PCR (+) 5) CR (chemo + imatinib): NA 5) 2nd alloSCT: Q-PCR (+); FISH (-)

p190 Chemo, imatinib, alloSCT

CR, alive, NA

Adriana52 19/M B-ALL 1) Onset: 46,XY[20]; FISH (-) 2) clinical remission (4 mo): NA; Q-PCR (+), 0.08%; FISH (-) 7 1st relapse

1) Initial: 46,XY[4]/46,XY,+6+4-9-12,19,+21,der(22)t(9;22)(q34;q11)[4]/73,XXYY,t(9;22)(q34;q11,der(22)t(9;22)(q34;q11)[17]; FISH (+), 90% 2) morphologic remission: 46,XY[20]; FISH 10%

p190 Chemo, dasatinib

Morphologic remission, lost in F/U, 1 mo

Abbreviations: AML, acute myeloid leukemia; MDS, myelodysplastic syndrome; EB, excess blast; CMML, chronic myelomonocytic leukemia; ALL, acute lymphoblastic leukemia; CR, complete remission; PR, partial remission; alloSCT, allogeneic stem cell transplant; SB, Southern blot; Q-PCR, reverse transcription quantitative polymerase chain reaction; IgH, immunoglobulin heavy chain; TCR-B, t-cell receptor beta; Ph, Philadelphia chromosome; chemo, conventional chemotherapy; NA, not available; M, male; F, female; FISH, fluorescence in situ hybridization studies; F/U, follow-up; mo, months; wk, weeks. #Dominant clone, please refer to original article for complete karyotype.