Micromegakaryocytes (microMKs) are considered the most reliable dysplastic feature for myelodyspl... more Micromegakaryocytes (microMKs) are considered the most reliable dysplastic feature for myelodysplastic syndrome (MDS), particularly refractory cytopenia of childhood (RCC); there is no minimal threshold for the diagnosis of RCC. Since most RCC patients present with thrombocytopenia, the presence of microMKs should raise concern for MDS/RCC. This study attempted to investigate the prevalence of microMKs and associated marrow fibrosis in patients with thrombocytopenia unrelated to MDS/RCC and the need for establishing a threshold for microMKs for the diagnosis of MDS/RCC. Bone marrow biopsies of pediatric patients with thrombocytopenia unrelated to RCC were examined for microMKs and fibrosis by CD61 immunohistochemical and reticulin stains respectively. Thirty eight patients (1-18 years old) were included: 33 immune thrombocytopenia (ITP), 3 chronic thrombocytopenia, and 2 inherited macrothrombocytopenia. Fourteen cases (37%) had microMKs; four cases showed increased marrow fibrosis associated with microMKs (two had ITP and two had macrothrombocytopenia). All patients are alive and none developed MDS (follow up: 3months to 4 years). MicroMKs can be seen in pediatric patients with thrombocytopenia unrelated to RCC. Hence the mere presence of microMKs is insufficient for the diagnosis of RCC in the pediatric population, and a quantitative threshold needs to be established.
Pediatric and Developmental Pathology, Aug 20, 2020
Young males have a unique but rare predilection to develop mediastinal nonseminomatous germ cell ... more Young males have a unique but rare predilection to develop mediastinal nonseminomatous germ cell tumors (NSGCTs) and concomitant acute megakaryoblastic leukemia (AMKL). Common cytogenetic and molecular abnormalities such as isochromosome 12p and somatic Tumor Protein P53(TP53) and Phosphatase And Tensin Homolog (PTEN) mutations have been reported in the presumed mutual neoplastic clones of origin. We report the case of a 17-year-old male who presented with a mediastinal NSGCT with high-grade sarcomatous transformation and a diagnosis of AMKL approximately 4 months later. Next-generation sequencing revealed identical KRAS Proto-Oncogene, GTPase (KRAS) p.Ala146Thr, TP53 p.Leu257Pro, and PTEN p.Leu181Pro missense mutations at similar variant allele frequencies in both the NSGCT and AMKL samples. Cytogenetic and microarray analyses detected shared copy gains in all chromosomes except chromosomes 9, 13, and Y. Multiple additional clonal chromosomal alterations were detected in the AMKL sample when compared with the NSGCT. This case emphasizes the shared clonal origins of these malignancies and identifies KRAS and other copy number alterations as potential molecular drivers in a subset of these combined diseases.
Letters submitted for possible publication must be identified as such and submitted with a signed... more Letters submitted for possible publication must be identified as such and submitted with a signed trans-fers f-copyright form (see Table of Contents for loca-tion). Text length must not exceed 400 words. No more than five references may be used; reference for-mat must be that ...
Supplemental material, sj-xlsx-1-pdp-10.1177_1093526620951327 for Mediastinal Germ Cell Tumor and... more Supplemental material, sj-xlsx-1-pdp-10.1177_1093526620951327 for Mediastinal Germ Cell Tumor and Acute Megakaryoblastic Leukemia With Co-occurring KRAS Mutation and Complex Cytogenetics by Nasir Amra, Luis Velasquez Zarate, Jyotinder N Punia, Priya Mahajan, Alexandra M Stevens, Angshumoy Roy, Choladda V Curry, Nahir Cortes-Santiago and Kevin E Fisher in Pediatric and Developmental Pathology
Mixed phenotype acute leukemia (MPAL) is a rare group of acute leukemias defined by immunophenoty... more Mixed phenotype acute leukemia (MPAL) is a rare group of acute leukemias defined by immunophenotypic expression of more than one hematopoietic cell lineage. The World Health Organization (WHO) diagnostic immunophenotypic criteria for MPAL rely on the intensity of lineage-defining antigen expression, predominantly a qualitative assessment, and are often difficult to apply to a phenotypically heterogeneous leukemia. Cases of MPAL defined by isolated myeloperoxidase (isoMPO) expression on otherwise typical acute lymphoblastic leukemia (ALL) are variably diagnosed as MPAL or ALL based on the incompletely defined criteria for assigning MPO expression. We hypothesized that quantitative criteria for antigen intensity could be developed and applied in a uniform manner across flow cytometry instruments, reagents, and analysis software to enable a consistent approach to diagnosing MPAL and better defining isoMPO. We previously reported on a multicenter cohort identified by respective institut...
Systemic EBV-associated T-cell lymphoproliferative disorders of childhood (S-EBV-T-LPD) comprise ... more Systemic EBV-associated T-cell lymphoproliferative disorders of childhood (S-EBV-T-LPD) comprise three major forms: EBV-positive hemophagocytic lymphohistiocytosis (EBV-HLH), systemic EBV-positive T- cell lymphoma (S-EBV-TCL), and systemic T-cell chronic active EBV infection (S-T-CAEBV). These disorders are rare in children and young adults in Western countries and are associated with poor outcomes. Frequently patients were treated initially for EBV-HLH and subsequently found to have relapsed/refractory EBV-HLH vs S-EBV-TCL or overt EBV+ TCL, the latter of which requires different therapy than EBV-HLH. We report the clinicopathologic findings of 13 cases, including 8 previously reported. (PMID: 31099136) Thirteen cases of S-EBV-T-LPD were identified at Texas Children’s Hospital from 1990 to 2020. Clinicopathologic and relevant laboratory parameters were recorded. Patients included six females and seven males of Hispanic (n=6), Asian (4), and Caucasian origins (3) ages 1-22 years (me...
Introduction: Mixed phenotype acute leukemia (MPAL) is a relatively rare and difficult to treat l... more Introduction: Mixed phenotype acute leukemia (MPAL) is a relatively rare and difficult to treat leukemia with features of at least two cell lineages (typically myeloid combined with B-ALL or T-ALL). Early abnormalities in hematopoiesis appear to result in specific types of bone marrow disorders and leukemias. Epigenetic changes, such as aberrant DNA methylation facilitated by mutated DNA methyltransferases, have been implicated in the pathogenesis of many hematopoietic disorders. A recent study of adult patients with T-ALL/myeloid mixed phenotype acute leukemia demonstrated a 50% mutation frequency in the DNMT3A gene (Kern et al., ASH 2012). Interestingly, a Dnmt3a-null mouse model in our lab develops both myeloid and lymphoid malignancies. We hypothesize that epigenetic genes are an important regulator of early stem cell differentiation and that mutations in these genes may cause abnormal stem cell differentiation resulting in the ambiguous phenomenon of mixed phenotype acute leuke...
BACKGROUND: Mixed phenotype acute leukemia (MPAL) is a rare form of leukemia in children. Current... more BACKGROUND: Mixed phenotype acute leukemia (MPAL) is a rare form of leukemia in children. Current evidence supports the use of acute lymphoblastic leukemia (ALL)-directed regimens as initial therapy for MPAL; Children's Oncology Group (COG) ALL regimens are commonly used for pediatric ALL in the United States. Data for the predictive value of minimal residual disease (MRD) to risk-stratify therapy for pediatric MPAL is sparse overall and currently unknown in the context of COG ALL regimens. The primary objective for this study was to therefore examine the predictive value of MRD for event-free and overall survival (EFS, OS) in a centrally-reviewed, strictly-defined pediatric MPAL cohort treated according to COG ALL regimens. METHODS: A retrospective cohort of pediatric MPAL treated from 2008-2016 was assembled from six institutions in the United States. All sites submitted primary diagnostic flow cytometry for central review. Two independent hematopathologists blinded to clinica...
INTRODUCTION: Mixed phenotype acute leukemia (MPAL) is a category of acute leukemia established i... more INTRODUCTION: Mixed phenotype acute leukemia (MPAL) is a category of acute leukemia established in the World Health Organization (WHO) 2001 classification, significantly modified in WHO2008, and again refined in the most recent WHO2016 update. The current WHO2016 iteration conceptualizes MPAL as a stem cell disorder whereby most cases will manifest heterogeneity of lineage-specific antigen expression by multi-parameter flow cytometry. The WHO2016 definition also urges caution for cases otherwise consistent with B-cell acute lymphoblastic leukemia (B-ALL) that express myeloperoxidase (MPO) as the sole representation of myeloid lineage. These cases met the WHO2008 definition but may not meet the newer WHO2016 criteria. There is limited data on the clinical impact of these recent changes in the WHO classification for MPAL. METHODS: Six institutions identified cases diagnosed as MPAL between 2008 and 2016 according to WHO criteria. The diagnostic flow cytometry was then reanalyzed by tw...
Introduction: The diagnosis and risk stratification for patients with B-lymphoblastic leukemia (B... more Introduction: The diagnosis and risk stratification for patients with B-lymphoblastic leukemia (B-ALL) requires the accurate detection of fusion genes such as BCR-ABL1, ETV6-RUNX1,or Philadelphia-like (Ph-like) B-ALL kinase fusions, or gene rearrangements (e.g. KMT2A). No single assay can detect all relevant alterations, so costly and inefficient testing algorithms that combine karyotyping, fluorescent in situ hybridization (FISH), and reverse transcriptase PCR (RT-PCR) are often required. A comprehensive and sensitive RNA-based next-generation sequencing (NGS) assay that could consolidate diagnostic and prognostic B-ALL gene fusion and rearrangement testing into a single clinical test is an attractive alternative. Methods: We obtained RNA from 15 clinical specimens collected from 14 patients [11 bloods (2 from the same patient) and 4 bone marrows] with hematologic malignancies and known genomic alterations by RT-PCR, FISH, or cytogenetics, and 1 Ph-positive B-ALL cell line (SUP-B15...
Micromegakaryocytes (microMKs) are considered the most reliable dysplastic feature for myelodyspl... more Micromegakaryocytes (microMKs) are considered the most reliable dysplastic feature for myelodysplastic syndrome (MDS), particularly refractory cytopenia of childhood (RCC); there is no minimal threshold for the diagnosis of RCC. Since most RCC patients present with thrombocytopenia, the presence of microMKs should raise concern for MDS/RCC. This study attempted to investigate the prevalence of microMKs and associated marrow fibrosis in patients with thrombocytopenia unrelated to MDS/RCC and the need for establishing a threshold for microMKs for the diagnosis of MDS/RCC. Bone marrow biopsies of pediatric patients with thrombocytopenia unrelated to RCC were examined for microMKs and fibrosis by CD61 immunohistochemical and reticulin stains respectively. Thirty eight patients (1-18 years old) were included: 33 immune thrombocytopenia (ITP), 3 chronic thrombocytopenia, and 2 inherited macrothrombocytopenia. Fourteen cases (37%) had microMKs; four cases showed increased marrow fibrosis associated with microMKs (two had ITP and two had macrothrombocytopenia). All patients are alive and none developed MDS (follow up: 3months to 4 years). MicroMKs can be seen in pediatric patients with thrombocytopenia unrelated to RCC. Hence the mere presence of microMKs is insufficient for the diagnosis of RCC in the pediatric population, and a quantitative threshold needs to be established.
Pediatric and Developmental Pathology, Aug 20, 2020
Young males have a unique but rare predilection to develop mediastinal nonseminomatous germ cell ... more Young males have a unique but rare predilection to develop mediastinal nonseminomatous germ cell tumors (NSGCTs) and concomitant acute megakaryoblastic leukemia (AMKL). Common cytogenetic and molecular abnormalities such as isochromosome 12p and somatic Tumor Protein P53(TP53) and Phosphatase And Tensin Homolog (PTEN) mutations have been reported in the presumed mutual neoplastic clones of origin. We report the case of a 17-year-old male who presented with a mediastinal NSGCT with high-grade sarcomatous transformation and a diagnosis of AMKL approximately 4 months later. Next-generation sequencing revealed identical KRAS Proto-Oncogene, GTPase (KRAS) p.Ala146Thr, TP53 p.Leu257Pro, and PTEN p.Leu181Pro missense mutations at similar variant allele frequencies in both the NSGCT and AMKL samples. Cytogenetic and microarray analyses detected shared copy gains in all chromosomes except chromosomes 9, 13, and Y. Multiple additional clonal chromosomal alterations were detected in the AMKL sample when compared with the NSGCT. This case emphasizes the shared clonal origins of these malignancies and identifies KRAS and other copy number alterations as potential molecular drivers in a subset of these combined diseases.
Letters submitted for possible publication must be identified as such and submitted with a signed... more Letters submitted for possible publication must be identified as such and submitted with a signed trans-fers f-copyright form (see Table of Contents for loca-tion). Text length must not exceed 400 words. No more than five references may be used; reference for-mat must be that ...
Supplemental material, sj-xlsx-1-pdp-10.1177_1093526620951327 for Mediastinal Germ Cell Tumor and... more Supplemental material, sj-xlsx-1-pdp-10.1177_1093526620951327 for Mediastinal Germ Cell Tumor and Acute Megakaryoblastic Leukemia With Co-occurring KRAS Mutation and Complex Cytogenetics by Nasir Amra, Luis Velasquez Zarate, Jyotinder N Punia, Priya Mahajan, Alexandra M Stevens, Angshumoy Roy, Choladda V Curry, Nahir Cortes-Santiago and Kevin E Fisher in Pediatric and Developmental Pathology
Mixed phenotype acute leukemia (MPAL) is a rare group of acute leukemias defined by immunophenoty... more Mixed phenotype acute leukemia (MPAL) is a rare group of acute leukemias defined by immunophenotypic expression of more than one hematopoietic cell lineage. The World Health Organization (WHO) diagnostic immunophenotypic criteria for MPAL rely on the intensity of lineage-defining antigen expression, predominantly a qualitative assessment, and are often difficult to apply to a phenotypically heterogeneous leukemia. Cases of MPAL defined by isolated myeloperoxidase (isoMPO) expression on otherwise typical acute lymphoblastic leukemia (ALL) are variably diagnosed as MPAL or ALL based on the incompletely defined criteria for assigning MPO expression. We hypothesized that quantitative criteria for antigen intensity could be developed and applied in a uniform manner across flow cytometry instruments, reagents, and analysis software to enable a consistent approach to diagnosing MPAL and better defining isoMPO. We previously reported on a multicenter cohort identified by respective institut...
Systemic EBV-associated T-cell lymphoproliferative disorders of childhood (S-EBV-T-LPD) comprise ... more Systemic EBV-associated T-cell lymphoproliferative disorders of childhood (S-EBV-T-LPD) comprise three major forms: EBV-positive hemophagocytic lymphohistiocytosis (EBV-HLH), systemic EBV-positive T- cell lymphoma (S-EBV-TCL), and systemic T-cell chronic active EBV infection (S-T-CAEBV). These disorders are rare in children and young adults in Western countries and are associated with poor outcomes. Frequently patients were treated initially for EBV-HLH and subsequently found to have relapsed/refractory EBV-HLH vs S-EBV-TCL or overt EBV+ TCL, the latter of which requires different therapy than EBV-HLH. We report the clinicopathologic findings of 13 cases, including 8 previously reported. (PMID: 31099136) Thirteen cases of S-EBV-T-LPD were identified at Texas Children’s Hospital from 1990 to 2020. Clinicopathologic and relevant laboratory parameters were recorded. Patients included six females and seven males of Hispanic (n=6), Asian (4), and Caucasian origins (3) ages 1-22 years (me...
Introduction: Mixed phenotype acute leukemia (MPAL) is a relatively rare and difficult to treat l... more Introduction: Mixed phenotype acute leukemia (MPAL) is a relatively rare and difficult to treat leukemia with features of at least two cell lineages (typically myeloid combined with B-ALL or T-ALL). Early abnormalities in hematopoiesis appear to result in specific types of bone marrow disorders and leukemias. Epigenetic changes, such as aberrant DNA methylation facilitated by mutated DNA methyltransferases, have been implicated in the pathogenesis of many hematopoietic disorders. A recent study of adult patients with T-ALL/myeloid mixed phenotype acute leukemia demonstrated a 50% mutation frequency in the DNMT3A gene (Kern et al., ASH 2012). Interestingly, a Dnmt3a-null mouse model in our lab develops both myeloid and lymphoid malignancies. We hypothesize that epigenetic genes are an important regulator of early stem cell differentiation and that mutations in these genes may cause abnormal stem cell differentiation resulting in the ambiguous phenomenon of mixed phenotype acute leuke...
BACKGROUND: Mixed phenotype acute leukemia (MPAL) is a rare form of leukemia in children. Current... more BACKGROUND: Mixed phenotype acute leukemia (MPAL) is a rare form of leukemia in children. Current evidence supports the use of acute lymphoblastic leukemia (ALL)-directed regimens as initial therapy for MPAL; Children's Oncology Group (COG) ALL regimens are commonly used for pediatric ALL in the United States. Data for the predictive value of minimal residual disease (MRD) to risk-stratify therapy for pediatric MPAL is sparse overall and currently unknown in the context of COG ALL regimens. The primary objective for this study was to therefore examine the predictive value of MRD for event-free and overall survival (EFS, OS) in a centrally-reviewed, strictly-defined pediatric MPAL cohort treated according to COG ALL regimens. METHODS: A retrospective cohort of pediatric MPAL treated from 2008-2016 was assembled from six institutions in the United States. All sites submitted primary diagnostic flow cytometry for central review. Two independent hematopathologists blinded to clinica...
INTRODUCTION: Mixed phenotype acute leukemia (MPAL) is a category of acute leukemia established i... more INTRODUCTION: Mixed phenotype acute leukemia (MPAL) is a category of acute leukemia established in the World Health Organization (WHO) 2001 classification, significantly modified in WHO2008, and again refined in the most recent WHO2016 update. The current WHO2016 iteration conceptualizes MPAL as a stem cell disorder whereby most cases will manifest heterogeneity of lineage-specific antigen expression by multi-parameter flow cytometry. The WHO2016 definition also urges caution for cases otherwise consistent with B-cell acute lymphoblastic leukemia (B-ALL) that express myeloperoxidase (MPO) as the sole representation of myeloid lineage. These cases met the WHO2008 definition but may not meet the newer WHO2016 criteria. There is limited data on the clinical impact of these recent changes in the WHO classification for MPAL. METHODS: Six institutions identified cases diagnosed as MPAL between 2008 and 2016 according to WHO criteria. The diagnostic flow cytometry was then reanalyzed by tw...
Introduction: The diagnosis and risk stratification for patients with B-lymphoblastic leukemia (B... more Introduction: The diagnosis and risk stratification for patients with B-lymphoblastic leukemia (B-ALL) requires the accurate detection of fusion genes such as BCR-ABL1, ETV6-RUNX1,or Philadelphia-like (Ph-like) B-ALL kinase fusions, or gene rearrangements (e.g. KMT2A). No single assay can detect all relevant alterations, so costly and inefficient testing algorithms that combine karyotyping, fluorescent in situ hybridization (FISH), and reverse transcriptase PCR (RT-PCR) are often required. A comprehensive and sensitive RNA-based next-generation sequencing (NGS) assay that could consolidate diagnostic and prognostic B-ALL gene fusion and rearrangement testing into a single clinical test is an attractive alternative. Methods: We obtained RNA from 15 clinical specimens collected from 14 patients [11 bloods (2 from the same patient) and 4 bone marrows] with hematologic malignancies and known genomic alterations by RT-PCR, FISH, or cytogenetics, and 1 Ph-positive B-ALL cell line (SUP-B15...
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