Myelodysplastic syndromes

Objective.-To describe the pathologic features of two cases of myelodysplastic syndrome associated with trisomy 14 and to summarize the relevant literature.

Results.-In both cases, trisomy 14 was identified using conventional cytogenetic and fluorescence in situ hybridization methods. The patients were elderly men, 70 and 77 years old, who presented with anemia and thrombocytopenia. According to the French-American-British classification, case 1 was classified as refractory anemia with ringed sideroblasts, and case 2 was classified as chronic myelomonocytic leukemia. In both cases, the aspirate smears revealed obvious abnormalities in erythroid and megakaryocytic maturation, with more subtle abnormalities in myeloid maturation. The biopsy sections were hypercellular, and there was marked myeloid hyperplasia in case 2. Both patients received only supportive therapy after the diagnosis was established. Clinical follow-up was available for both

patients. The patient in case 1 died 67 months after disease onset of an unrelated illness, and the patient in case 2 was alive at last follow-up, 12 months after diagnosis.

Literature Review.-Thirty-five cases of trisomy 14 have been previously reported in the literature, predominantly in cytogenetics journals, and the description of the pathologic findings for the majority of these cases is limited or not provided. According to published data, the majority of these cases are myelodysplastic syndromes or acute myeloid leukemias associated with myelodysplasia.

Conclusions.-The detection of trisomy 14 in the bone marrow strongly correlates with the presence of a myelodysplastic syndrome. The two cases of myelodysplastic syndrome associated with trisomy 14 we describe here did not exhibit characteristic morphologic findings that might suggest the presence of the cytogenetic abnormality.

(Arch Pathol Lab Med 1998;122:77-83)

Acquired trisomy 14 is an uncommon nonrandom chromosomal abnormality that is predominantly associated with disorders of myeloid lineage. To our knowledge, thirty-five cases have been reported previously, either as specific case studies or as a part of large studies of cases analyzed using conventional cytogenetics.1-23 Trisomy 14 cases have been assigned a variety of pathologic diagnoses, the most common being myelodysplastic syndrome (MDS), acute myeloid leukemia, and myeloproliferative disorder. Most recent studies have suggested that trisomy 14 is associated with advanced patient age and dysmyelopoiesis. Few studies, however, have emphasized the pathologic findings in these cases, nor have many cases been reported in the pathology literature.

In this study, we report two additional cases of trisomy 14, both associated with MDS, and focus on the pathologic findings in cases associated with this cytogenetic abnormality. We have also reviewed the literature pertaining to previously reported cases of trisomy 14.

REPORT OF CASES

Case 1

A 77-year-old man presented with anemia and thrombocytopenia. A bone marrow aspirate and biopsy were interpreted as an MDS consistent with refractory anemia. Six months later, the patient presented with shortness of breath and a right pleural effusion. Cytologic examination of pleural fluid showed no evidence of tumor. The patient's shortness of breath improved following transfusion of three units of blood and the pleural effusion was thought to be secondary to congestive heart failure. The patient refused bone marrow aspiration or biopsy. The patient was re-examined 40 months later owing to persistent anemia and transfusion dependence. A bone marrow biopsy was hypercellular with marked erythroid hyperplasia and contained numerous ringed sideroblasts (see "Results"). Conventional cytogenetic studies and fluorescence in situ hybridization showed trisomy 14.

During the next 26 months, the patient remained dependent on transfusions but received no specific therapy. He then presented with shortness of breath and a markedly increased serum lactate dehydrogenase level. A bone marrow biopsy at this time revealed extensive replacement of the medullary space by metastatic poorly differentiated carcinoma. The patient died 3 days later. Permission to perform an autopsy was denied.

Case 2

A 70-year-old man was found to have anemia, thrombocytopenia, and slight leukocytosis during a routine workup for coronary artery disease. Peripheral blood smear revealed anisocytosis and poikilocytosis with increased polychromasia. Bone marrow aspirate and biopsy specimens were markedly hypercellular with marked myeloid hyperplasia and a left shift in myeloid maturation (see "Results"). One month later, a sternal bone marrow aspirate revealed a marked increase in myeloid precursors with hypogranular and hypolobated forms. Conventional cytogenetic studies revealed trisomy 14. The patient was treated with vitamin B^sub 6^, folic acid, erythropoietin, and red blood cell transfusions. The transfusion requirement progressively increased over time.

One year after initial presentation, the patient presented with moderate leukocytosis with increased monocytes. A bone marrow aspirate and biopsy was markedly hypercellular and showed a marked increase in myeloid precursors and hypolobated megakaryocytes. Monocytoid cells were mildly increased (see "Results"). The findings were interpreted as an MDS, consistent with chronic myelomonocytic leukemia. Trisomy 14 was detected in this bone marrow aspirate using both conventional cytogenetic studies and fluorescence in situ hybridization methods.

MATERIALS AND METHODS

Air-dried bone marrow aspirate smears from both cases were stained with Wright-Giemsa for routine morphologic evaluation. The bone marrow trephine biopsy and aspirate clot specimens were fixed in B5 or 10% buffered formalin, processed routinely, and stained with hematoxylin-eosin.

Cytogenetic Studies

Conventional cytogenetic studies were performed on cell cultures obtained from bone marrow aspirate material on both patients using routine GTG banding. For patient 1, 23 and 20 cells in metaphase were analyzed from two separate bone marrow samples obtained at the City of Hope National Medical Center, Duarte, Calif, with an interval of 26 months. For patient 2, studies were done initially at another institution and were repeated at the City of Hope National Medical Center 11 months later. Twenty and 30 cells in metaphase were analyzed, respectively.

Fluorescence In Situ Hybridization

Fluorescence in situ hybridization was performed on previously saved cell suspensions of both patients. Briefly, methanolacetic acid-fixed suspended cells were dropped on cleaned glass slides. The slides were allowed to air dry, prewarmed at 37 degrees C for 10 minutes, and hybridized using a digoxigenin-labled telomeric 14q DNA probe according to the manufacturer's protocol (Oncor, Gaithersburg, Md). Using an epifluorescence microscope (Nikon Inc, Garden City, NY), hybridization signals were counted in at least 200 cells from control and patient specimens, and representative photographs were taken.

RESULTS

Patient 1

The initial complete blood cell count revealed the following values: red blood cell (RBC) count, 1.97 x 10^sup 12^/L; hemoglobin (Hb), 61 g/L; hematocrit (Hct), 0.19; mean corpuscular volume (MCV), 96 fL; platelet count, 125 x 10^sup 9^/L; and white blood cell (WBC) count, 4.6 x 10^sup 9^/L with 55% neutrophils, 2% bands, 37% lymphocytes, and 6% monocytes. The bone marrow aspiration and biopsy showed normocellular bone marrow (cellularity, 50%) with marked erythroid hyperplasia. Dysplasia involving erythroid and megakaryocytic cell lines was present. Erythroid precursors had abnormal nuclear lobation, and megakaryocytes had hypolobated nuclei. Myeloid maturation was orderly without increased blasts. Ringed side- roblasts were not identified. The morphologic findings in this bone marrow specimen were interpreted as an MDS, most consistent with refractory anemia.

A complete blood count 40 months later revealed an RBC count of 3.2 x 10^sup 12^/L; Hb, 91 g/L; Hct, 0.28; MCV, 87 fL; platelet count, 56 x 10^sup 9^/L; and WBC count, 6.8 x 10^sup 9^/L with 40% neutrophils, 3% basophils, 38% lymphocytes, and 19% monocytes. Anisocytosis, poikilocytosis, and large platelets were observed in the peripheral blood smear. The leukocytes were normal. Bone marrow aspiration and biopsy, compared with the prior specimen, revealed increased bone marrow cellularity with marked erythroid hyperplasia and a left shift in erythroid maturation. Rare dyserythropoeitic cells with irregular nuclei, nuclear/cytoplasmic dyssyncrony, and many abnormal hypolobated megakaryocytes were present (Fig 1, A and B). Iron stores were increased, and numerous ringed sideroblasts were identified. The morphologic findings in these specimens were also interpreted as an MDS, best classified as refractory anemia with ringed sideroblasts using the French-American-British (FAB) classification. Conventional cytogenetic studies revealed a 47,XY,+14 karyotype in 21 of 23 metaphases. Two of 23 metaphases showed a normal male karyotype.

A complete blood count (67 months after initial presentation) revealed the following values: RBC count, 3.37 x 10^sup 12^; Hb, 99 g/L; Hct 0.29; platelet count, 46 x 10^sup 9^; and WBC count, 10.4 x 10^sup 9^ with 78% neutrophils, 1% myelocytes, 8% lymphocytes, and 13% monocytes. Rare pseudo- Pelger-Huet forms and hypogranular neutrophils were noted on the peripheral blood smear. A third bone marrow aspirate and biopsy (67 months after initial presentation) showed a left shift in myeloid maturation without increased blasts. Erythroid maturation was shifted to the left, and rare abnormal erythroid forms with nuclear irregularity were identified. Megakaryocytes were moderately decreased and hypolobated. An iron stain revealed increased iron stores with scattered ringed sideroblasts. No carcinoma cells were seen in the aspirate smear. The trephine biopsy showed extensive replacement of the medullary space by metastatic, poorly differentiated carcinoma. Immunohistochemical studies performed on fixed, paraffin-embedded tissue sections revealed that the neoplastic cells were positive for keratin and negative for leukocyte common antigen (CD45/CD45RB).

Cytogenetic studies performed on two separate samples of bone marrow aspirate-cultured cells obtained at 40 months and 67 months after presentation revealed a 47,XY+14 karyotype in 21 of 23 and 14 of 20 metaphases, respectively. Two of 23 metaphases in first sample and five of 20 metaphases in second sample showed a normal male karyotype. One cell in the second sample was karyotypically abnormal in the near-triploid range. Trisomy 14 was also identified using fluorescence in situ hybridization in both bone marrow aspirate samples.

Patient 2

A complete blood count at the time of initial presentation revealed the following values: Hb, 99 g/L; platelet count, 73 x 10^sup 9^; and WBC count, 13.8 x 10^sup 9^. One month later, a complete blood count revealed an RBC count of 2.4 x 10^sup 12^/L; Hb, 78 g/L; Hct, 0.24; MCV, 100 fL; platelet count, 102 x 10^sup 9^/L; and WBC count, 15.1 x 10^sup 9^/L with 82% neutrophils, 2% bands, 3% myelocytes, 2% metamyelocytes, 9% lymphocytes, and 2% monocytes. A peripheral blood smear showed increased anisocytosis, poikilocytosis, and polychromasia with rare nucleated erythrocytes. Neutrophil morphology could not be reliably assessed because the smear was of suboptimal staining quality. Moderate thrombocytopenia was noted. The initial bone marrow aspirate smears and trephine biopsy sections showed markedly hypercellular bone marrow (cellularity, 100%) with marked myeloid hyperplasia and a left shift in myeloid maturation without dysplastic neutrophils. Rare erythroid precursors exhibited abnormally lobated and pyknotic nuclei. Megakaryocytes were increased, and many of them had abnormal hypolobated nuclei. No cytogenetic studies were performed.

Two months after initial presentation, a complete blood count revealed the following values: Hb, 100 g/L; Hct, 0.31; MCV 97.5 fL; red blood cell distribution width, 26.6; platelet count, 119 x 10^sup 9^/L; and WBC count, 12.2 x 10^sup 9^ with 38% segmented neutrophils, 11% myelocytes, 4% metamyelocytes, 21% bands, 2% eosinophils, 15% lymphocytes, and 9% monocytes. The peripheral blood smear revealed anisocytosis and poikilocytosis with macrocytes, tear drop forms, and erythrocyte fragments. Rare nucleated erythrocytes with irregular lobated nuclei were present. Hypogranular and hypolobated neutrophils were not identified. A sternal bone marrow aspirate revealed cellular bone marrow particles with a marked increase in myeloid precursors and a left shift in myeloid maturation. Dysplastic myeloid cells with hypogranular cytoplasm and hypolobated nuclei were present. Many dysplastic megakaryocytes with hypolobated nuclei were also seen. Iron incorporation was increased, but no ringed sideroblasts were identified.

One year after initial presentation, a complete blood count revealed an RBC count of 2.80 x 10^sup 12^/L; Hb, 88 g/L; Hct, 0.26; MCV, 92.4 fL; platelet count, 37 x 10^sup 9^/L; and WBC count, 19.2 x 10^sup 9^ / L with 58% neutrophils, 7% myelocytes, 7% metamyelocytes, 4% bands, 14% lymphocytes, and 10% monocytes. The absolute monocyte count was 1.92 x 10^sup 9^. The peripheral blood smear revealed rare pseudo-Pelger-Huet forms, anisocytosis, poikilocytosis, and thrombocytopenia (Fig 2). A third bone marrow aspirate and biopsy specimen was markedly hypercellular with a marked increase in myeloid precursors and many hypolobated megakaryocytes (Fig 3, A and B). Monocytes were mildly increased, highlighted by an alpha-naphtyl butyrate esterase stain. An iron stain showed normal iron stores with increased iron incorporation. Ringed sideroblasts were not identified. The findings in this specimen were interpreted as a myelodysplastic syndrome, consistent with chronic myelomonocytic leukemia using the FAB classification.

Conventional cytogenetic studies of the second and third bone marrow aspirate specimens (obtained 2 months and 12 months after presentation, respectively) revealed trisomy 14 as the only abnormality in 4 of 20 metaphases and 3 of 30 metaphases, respectively. Trisomy 14 was also identified using fluorescence in situ hybridization in the third bone marrow aspirate specimen.

COMMENT

We describe two patients with trisomy 14 associated with an MDS, diagnosed as refractory anemia with ringed sideroblasts and chronic myelomonocytic leukemia according to FAB criteria. In our review of the English literature, we identified 35 additional patients with hematologic disorders associated with trisomy 14 (Table 1).1-22 All of the reported cases had cytogenetic evidence of trisomy 14 or isochromosome 14q. Seven cases had a complex karyotype with cytogenetic abnormalities in addition to trisomy 14. These additional abnormalities included i(Xq), t(1;13), t(3;3) with del(20)(q11q13), hyperdiploid unclassifiable chromosomes, and del(20q) in one patient each, and -Y in two patients.

A variety of pathologic diagnoses have been proposed for the 35 cases reported in the literature (Table 2), including various FAB types of MDS, poorly characterized myeloproliferative disorders (including Philadelphia chromosome-negative chronic myelogenous leukemia, atypical chronic myelogenous leukemia, and undifferentiated myeloproliferative disorder), acute myelogenous leukemia, aplastic anemia, and two lymphoid neoplasms (one case of large granular lymphocyte leukemia and one case of large cell immunoblastic lymphoma).5-18

Despite the large number of diagnoses in the literature, it appears that trisomy 14 is usually associated with MDS. Twenty (57%) of 35 cases have been previously reported with the diagnosis of MDS. These cases include all FAB subtypes, with no particular association with any subtype. The majority of the remaining cases are also probably examples of MDS. For example, others presently believe that most cases previously reported as atypical chronic myelogenous leukemia (CML) or Philadelphia chromosome- negative CML are example of MDS.24-28 Thus, the four cases of atypical CML,9 the case of undifferentiated myeloproliferative disorder,6 and a case of Philadelphia chromosome-negative CML[2] reported previously to be associated with trisomy 14 are probably examples of MDS. Also, seven trisomy 14 cases presented with acute myelogenous leukemia at the time of diagnosis.3,4,8,19,22 In some of these cases, background trilineage dysplasia was described. Furthermore, these patients ranged in age from 48 to 70 years, and five of seven were older than 60 years. Elderly patients with acute myelogenous leukemia commonly also have either clinical findings or cytogenetic abnormalities that suggest an associated MDS.27

Both of the cases we studied presented with anemia and thrombocytopenia and had dysplasia in the bone marrow involving the erythroid and megakaryocytic cell lines as common features. The myeloid cell line in case 1 was essentially normal. This patient had a normal WBC count and a normocellular bone marrow with erythroid hyperplasia. Abnormalities in myeloid maturation were identified in case 2. This patient had an elevated WBC count with a markedly hypercellular bone marrow with myeloid and megakaryocytic hyperplasia.

The clinical and morphologic findings in the two cases we studied are similar to other trisomy 14 cases previously reported by others. The majority of patients are elderly and present with anemia and thrombocytopenia. The WBC count is variable; although most cases present with leukopenia, the WBC count can be normal or elevated. The cases with leukocytosis may mimic a myeloproliferative disorder or a poorly defined hematopoeitic disorder with features of both myeloproliferative disorder and MDS. Unlike the two cases we report, approximately half of previously reported cases of MDS associated with trisomy 14 have had prominent dysmyelopoiesis. The pathologic findings in the two cases we report and those reported by others do not demonstrate distinctive or specific morphologic abnormalities.

Clinical follow-up of patients with trisomy 14-associated hematologic disorders is available for 32 (86%) of 37 patients. Nineteen patients died, and 13 patients were alive at last follow-up. Fourteen patients died with their hematologic neoplasms, with survival ranging from 2 to 75 months (5 acute myelogenous leukemia, 4 atypical CML, 1 Philadelphia chromosome-negative CML, 1 chronic myelomonocytic leukemia, 1 refractory anemia with excess of blasts, 1 with refractory anemia with excess of blasts in transformation, and 1 immunoblastic lymphoma). Eleven patients were alive with their hematologic disorder, with follow-up of 2 to 48 months (6 MDS, 1 acute myelogenous leukemia arising in agnogenic myeloid metaplasia, 1 de novo acute myelogenous leukemia, 1 atypical CML, 1 aplastic anemia, and 1 large granular lymphocytic leukemia). Four patients died of infections, and four died of unrelated diseases.

Among the reported trisomy 14 cases, two patients presented with a lymphoid neoplasm. One patient had large granular lymphocytic leukemia,5 and the other patient had large cell immunoblastic lymphoma.18 The concurrent appearance of lymphoid neoplasms with trisomy 14 is extremely rare. Whether this represents a true association or an MDS coexisting with malignant lymphoma is uncertain.

In summary, we conclude that acquired trisomy 14 or isochromosome 14q is a rare, nonrandom cytogenetic abnormality that is most often associated with MDS with no particular preference for any FAB subtype. In the two cases we report, and from our review of the literature, the morphologic features of MDS associated with trisomy 14 are not sufficiently distinctive to allow one to suggest the presence of the cytogenetic abnormality on the basis of morphologic review.

References

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Accepted for publication July 9, 1997.

From the Division of Pathology, City of Hope National Medical Center, Duarte, Calif.

Reprint requests to Division of Pathology, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010 (Dr Medeiros).

Copyright College of American Pathologists Jan 1998
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