Characterization of a case of follicular lymphoma transformed into B-lymphoblastic leukemia
- Yi Ning†1,
- Aubry Foss†2,
- Amy S Kimball3,
- Nicholas Neill2,
- Tricia Matz2 and
- Roger Schultz2Email author
© Ning et al.; licensee BioMed Central Ltd. 2013
Received: 14 July 2013
Accepted: 1 August 2013
Published: 28 August 2013
Follicular lymphoma (FL) is a common form of non-Hodgkin lymphoma with an ability to transform into a more aggressive disease, albeit infrequently to B-lymphoblastic leukemia/lymphoma. While t(14;18)(q32;q21) has been associated with approximately 90% cases of FL, that alteration alone is insufficient to cause FL and associated mutations are still being elucidated. The transformation of FL to B-lymphoblastic leukemia generally includes the dysregulation of MYC gene expression, typically through IGH rearrangement. Such cases of “double-hit” leukemia/lymphoma with both BCL2 and MYC translocations warrant further study as they are often not identified early, are associated with a poor prognosis, and are incompletely understood in molecular terms. Here we describe a patient with a diagnosis of FL that transformed to B-lymphoblastic leukemia. Detailed cytogenetic characterization of the transformed specimen using karyotype, fluorescence in situ hybridization, microarray and gene rearrangement analyses revealed a complex karyotype comprised principally of whole chromosome or whole arm copy number gains or losses. Smaller, single-gene copy number alterations identified by microarray were limited in number, but included amplification of a truncated EP300 gene and alterations in NEIL1 and GPHN. Analyses defined the presence of an IGH/BCL2 fusion due to a translocation as well as a MYC/IGH fusion due to an insertion, with both rearrangements involving the same IGH allele. The data illustrate the value in characterizing double-hit lymphoma cases with both traditional and novel technologies in the detailed cytogenetic workup.
Follicular lymphoma (FL) accounts for approximately 30% of adult non-Hodgkin lymphoma and is generally indolent in its clinical course. A subset of FL cases transform into a more aggressive disease, most often to diffuse large B-cell lymphoma . Transformation to other entities, such as B- acute lymphoblastic leukemia (B-ALL), is less common [1–3]. FL is genetically characterized by the presence of the t(14;18)(q32;q21) chromosomal translocation in approximately 90% of cases . However, that alteration alone is insufficient to cause FL and those additional genomic events specifically leading to disease are still being elucidated. Similarly, those events that mediate transformation of FL to B-ALL remain under investigation, although dysregulation of MYC gene expression typically through rearrangement with the immunoglobulin (IG) locus is a common finding. Such cases of “double-hit” leukemia/lymphoma, defined by a translocation involving MYC in combination with another translocation involving BCL2, warrant further study as they are not readily recognized until transformation has occurred and are associated with a poor prognosis [5, 6]. Here we describe a patient with an initial diagnosis of FL that transformed to B-ALL. Detailed molecular and cytogenetic characterization of the transformed specimen using karyotype, fluorescence in situ hybridization (FISH), microarray and gene rearrangement analyses revealed the complex nature of the abnormalities present in this disease. These findings included a karyotype with 84-86 chromosomes, principally of whole-chromosome/whole-arm abnormalities, both IGH/BCL2 and MYC/IGH fusions involving the same single IGH allele, as well as limited single-gene alterations involving NEIL1, GPNH, and EP300.
A 52-year-old man presented with early satiety, fevers and myalgias. His past medical history was remarkable for recent recurrent methicillin- resistant Staphylococcus aureus (MRSA) cellulitis. On biopsy, an inguinal lymph node was involved with back-to-back lymphoid follicles containing cells with vesicular chromatin and prominent nucleoli. The cells of interest were CD45+, CD20+, CD10+, BCL2+, BCL6+ and kappa restricted; ki-67 stained 30-40% of the cells. A diagnosis of follicular lymphoma was made and staging studies revealed stage 3 disease, with supraclavicular, precarinal, mediastinal, periaortic, iliac and inguinal adenopathy, and splenomegaly. Lactate dehydrogenase (LDH) was modestly elevated. R-CHOP therapy was initiated with two cycles given 32 days apart. The patient’s symptoms resolved and he did not receive additional therapy. PET/CT imaging done 8 weeks and 6 months after cycle 2 showed resolution of adenopathy, splenomegaly and hypermetabolic activity.
Six months later the patient re-presented with early satiety, easy bruising and fatigue. His CBC showed WBC 7,000/ul with 20% circulating blasts, Hemoglobin 6.6 g/dL and platelet 9,000/ul. LDH was within normal limits. A PET/CT revealed enlarged hypermetabolic lymph nodes in the neck and chest. Splenomegaly was again seen. A bone marrow aspirate and biopsy showed >95% cellularity; 65% of the cells were lymphoblasts with CD10+ CD19+ CD38+ CD58+ CD71+ HLA DR+CD79+ and dim surface lambda positivity. CD20 and kappa were negative. Fine needle aspiration of a supraclavicular lymph node yielded a population of lymphoblasts with the same immunophenotype as the marrow infiltrating cells. A diagnosis of B-cell ALL was made. The patient was treated with 8 cycles of hyperCVAD/MTX-AraC, enjoyed a brief remission, but subsequently relapsed. He refused additional aggressive care and died shortly after relapse.
Molecular and cytogenetic studies
Karyotype and microarray findings in patient
Clinically significant aCGH findings
Gene-specific alterations (<1 Mb)
84-86<3n>,XXY,+X,+Y,+1,+2,+2,+5, +del(6)(q13)x2,+del(7)(q11.2),-8,-9, +11,-12, add(13)(q31)x2,-15,-17, del(18)(q21.1),+20,+21,+21,+21, +22,+4-6mar[cp10]
Follicular lymphoma transforming into acute lymphoblastic leukemia has been documented in a limited number of cases [2, 3, 11, 12]. “Double-hit” B-cell malignancies with both BCL2 and MYC rearrangements have also been reported in de novo large B-cell lymphoma  and Burkitt’s lymphoma/leukemia with three-way translocation t(8;14,18) . Such “Double-hit” B-cell malignancies are characterized by an extremely aggressive course and a high relapse rate [5, 6, 13, 14]. Given the initial diagnosis of follicular lymphoma in our case, IGH/BCL2 fusion was likely the first event, with MYC/IGH fusion arising secondarily and accompanying a complex karyotype. An early specimen at the time of diagnosis of FL was not available for this case.
Double-hit translocations in leukemia or lymphoma rarely occur at a single immunoglobulin locus. Knezevich et al. reported the detection of a complex der(8)t(8;14;18) in a few cases with a MYC/IGH/BCL2 rearrangement resulting from translocation of BCL2 and MYC involving a single disrupted IGH allele . Molecular cytogenetic investigation is essential to identify and characterize such cases. In our case the IGH breakpoints for the BCL2 and MYC rearrangements were located within the switch region ([hg18] Chr14:105140803-105142224) and at the start of the joining region ([hg18] Chr14:105400386-105400678), respectively, which is consistent with the previous reports . The MYC breakpoint was located within intron 1 ([hg18] Chr8:128818114-128818314), which is also a recurrent site. Most cases of sporadic Burkitt lymphoma and B-ALL exhibit MYC breakpoints either in the first intron, the first exon, or upstream of the gene . In contrast, the breakpoint for BCL2 was detected at the 5’ end of the gene ([hg18] Chr18:59135900-59136028). This is atypical, as BCL2 rearrangements predominantly involve defined major and minor breakpoint regions, both of which are 3’ of the gene . 5’- BCL2 breakpoints have been described, but these are rare and nearly always involve the immunoglobulin light chain, not seen in this case.
In addition to the MYC/IGH/BCL2 rearrangement, microarray analysis detected copy number alterations in this case. Although the majority of the alterations were large and involved whole chromosomes or whole arm loss or gain, a few smaller alterations, including deletion of NEIL1, mosaic single copy gain of GPHN, and amplification of a truncated EP300 allele were identified. NEIL1 is a member of the Nei endonuclease VIII-like gene family which encodes DNA glycosylases. The NEIL1 encoded enzyme catalyzes the removal of specific oxidative damage from DNA and interacts with key factors in cell cycle checkpoints and repair. NEIL1 is among the genes for which expression levels have been used to distinguish subtypes of diffuse large B cell lymphoma . GPHN (for gephyrin, from the Greek word for “bridge”) is a neuronal receptor assembly protein that links membrane-associated receptor molecules to cytoskeletal microfilaments. Interestingly, GPHN has been shown as a fusion partner of MLL in leukemia, and the MLL-GPHN fusion gene can transform hematopoietic progenitors . GPHN has also been found to be upregulated by a B-cell- activating factor as part of a cascade of events that inhibit CD20-mediated and B-cell receptor-mediated apoptosis in human B cells . EP300 encodes the adenovirus E1A-associated cellular p300 transcriptional co-activator protein. It functions as a histone acetyltransferase that regulates transcription via chromatin remodeling and is important in the processes of cell proliferation and differentiation. Mutations in EP300 and the highly related CREBBP are the most frequent structural abnormalities in follicular lymphoma and diffuse large B-cell lymphoma [20, 21]. In addition, acquisition of EP300 mutation has recently been shown in the progression of severe congenital neutropenia to acute myeloid leukemia . The findings of these additional aberrations may represent events facilitating the transition of FL to B-ALL. The results presented in this study identified genomic alterations with potential relevance to transformation and emphasize the value of employing diverse cytogenetic techniques in the workup of cases of leukemia and lymphoma.
Written informed consent was obtained for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank Erin Dodge and Michelle Caldwell for their help in generating the figures and editing the text for the preparation of this manuscript. We thank Victoria Cawich, Caitlin Valentin, Sara Minier, S. Annie Morton, Steve Byerly, and Melanie Anderson for their technical assistance and thoughtful insights in compiling these results for presentation. All of the above are employees of Signature Genomic Laboratories. We also thank the patient’s family for giving permission to publish this report.
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