Evidence for the Clonal Origin of Chronic Myeloid

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Evidence
for the Clonal
Origin
of Chronic
Myeloid
Leukemia
From a Sex Chromosome
Mosaic:
Clinical,
Cytogenetic,
and Marrow
Culture
Studies
By M.A.S.
Cytogenetic
senting
studies
with
tures
of
vealed
chronic
marrow
on
subsequent
of
(CFCs)
initial
were
and
midine
presentation
that
greatly
increased
the
low
in the
abnormal
which
tained
colonies
in
growth
the
buoyant
to tritiated
distinguishes
thy-
metaphase
and
an
sex
further
cell type,
whereas
occurrence
(CML)’
,2
nature
which
leukeniias
of the
coincidentally
may
with
clarify
origin
chromosome
pathogenesis
may
in mosaicism
of
further
emergence
be of both
) in chronic
(Ph’
sex chromosome
the
for
that
cyto-
of
the
Ph’
chromosome.
of multiclonal
Philadelphia
co-
mosa-
indicates
RELEVANT
TO the uniclonal
or multiclonal
origin
cells can be derived
from the study
of patients
with two or more
tinguishable
by genetic
markers.
Leukemias
of uniclonal
origin
should
The
The
support
and
risk
with
in vitro
culture.
I NFORMATION
other
of
leukemic
implicated
increased
evolution
ob-
chromosome
of CML
instability
carry
in
were
analysis
provides
origin
persisted
displaying
in agar
CML
in this patient
genetic
leukemic
clusters
cytogenetic
of
transforma-
Ph’
clusters
uniclonal
may
acute
was lost but small,
cell
XV,
and
cytogenetic
circulation
light
46
characteristics
icism
in
cells
During
capacity
following
existence
capacity
susceptibility
killing
A
Assessment
colony-forming
Only
in
and
normal.
differentiated
culture.
marrow.
predominated
transformation.
revealed
possessed
density
and
line
A. Carmichael
colony-forming
poorly
reXVV
and
from
tion
fea-
(CML)
Fitzgerald,
CFCs
pre-
XV/47
colony-forming
culture
and
cell
acute
granulocytic
agar
leukemia
blood,
Ph1
child
46
skin,
XV,
MG.
hematological
myeloid
in
46
H. Ekert,
a 7--yr-oId
and
constitutional
mosaicism
the
on
clinical
a
third
Moore,
mosaicism
of the
cell types.
myeloid
provides
disease
of leukemic
cell lines disbe of one or
leukemia
an experiment
process.
Two
such
of
patients
have been
described
both
showing
a Ph’
chromosome
and a Klinefelter’s
mosaicism,3’4
but in only one4 could
the findings
be readily
interpreted
as supporting
the
clonal
origin
of CML.
On the other
hand, studies
on CML using Xg blood groups
have
brought
into question
its clonality.7
Recent
advances
in tissue
culture
methodology
monocyte
stem
cells by their capacity
to form
allow
colonies
and
CML
peripheral
blood
colony-forming
From
Victoria,
The Cancer
Australia,
Victoria,
Australia.
Submitted
cultures
cells
April
from
(CFCs)
revised
June
23,
Supported
by (lie (‘arden
Fellowship
tional
Health
and Medical
Research
National
Cancer Institute,
NIH.
M.A.S.Moore,
D.Phil.:
Institute,
Royal
rector,
Haematology
gerald,
B.Sc.:
Victoria,
Parkeville,
Blood,
Vol.
by
Clinic,
A.
Grune
43,
No.
of
Funded
Medical
revealed
June
by
Royal
Children
29,
Parkville,
Royal
Registrar,
Melbourne
‘s Hospital.
of
Contract
Ekert,
granulocytic
disorder,9”#{176} and
Hospital,
Parkville,
1973.
c’oundil
Research
H.
that
in this
Institute,
Royal
Cancer
Pathology,
B.S.:
have
in number
A iiti-Cancer
Australia.
Hospital,
Children’s
MB.,
accepted
the
Fellow,
Victoria,
Department
Carmichael,
of
C’ouncil.
Research
Royal
1973;
Fund
Hospital,
Cvtogeneticist,
Victoria,
© 1974
Senior
Melbourne
Australia.
with
increased
Unit,
Walter
and Eliza
Hall
Department
of Haeinatology,
Research
and
tile
2, 1973;
patients
are greatly
detection
of granulocytein agar culture.68
Marrow
Victoria
NO
Unit,
M.B.,
Walter
Royal
and
l’.R.A.C.P.:
Victoria,
C’hildren
and
1-fB-3385
Australia.
‘5
Hospital,
Children’s
The
Na-
from
the
Eliza
Hall
Di-
Deputy
MG.
1’itz-
Parkeville.
Hospital,
A ustralia.
& Stratton,
1 (January),
Inc.
1974
15
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16
MOORE
that
are
abnormalities
in differentiation,
evjdent.”4
herald
ity.9”’4
Alterations
proliferative
of in vitro
acute
transformation
Cytogenetic
analysis
status,
growth
and generally
of granulocytic
and
CFC
characteristics
involve
colonies
have
buoyant
been
peripheral
we
blood
cytogenetically
gether
with
genetic
methods
was
that
and
the
clinical
to
resolve
the
chronic
and
cells
with
leukemic
of the 46 XY cell line,
thus
CASE
N.P.,
a Greek
hemorrhagic
and
3-cm
the
80th
male
variceila
aged
rash,
features,
in a child
with
XYY mosaic.
of circulating
used
in both
equivocally
the
culture
a 46 XY/47
characterizations
populations
positive
describe
agar
if
yr. was first
fundal hemorrhages,
CML
cytogenetic
with
data,
a Ph’
coexisting
acute
normal
phase
growth
and
of CML.
characteristics
supporting
have genHowever,
colonies
in
and
leukemic
The
origin
studies
of
who
was
culture
toand cytohemopoietic
studies
were
a uniclonal
to
capaccultures
chromosome
A combination
of in vitro agar
CFCs by physical,
functional,
AL.
density
reported
loss of colony-forming
developing
in marrow
from
patients
with
CML in relapse,
remission,
and acute
transformation
erally confirmed
the exclusive
proliferation
of Ph’ positive
21516
one report
described
coexisting
Ph’ positive
and cytogenetically
normal
CML cultures.’7
In this paper
ET
showed
exclusively
unPh’
of CML.
HISTORY
seen on August
generalized
22,
1972.
lymphadenopathy,
Examination
revealed
a
3-cm hepatomegaly,
splenomegaly.
Height was at the 90th percentile,
and weight and head circumference
at
percentiles.
I.Q. testing
showed
a level of 80. The child appeared
to be aggressive.
He had
brachycephaly
and clinodactyly
of the fifth fingers,
but was otherwise
a phenotypically
normal
male with normal
dermatoglyphic
patterns.
A diagnosis
of CML was made on the basis of hematological
and bone marrow
aspirate
results (Table 1).
Treatment
with busulphan,
2 mg daily,
was commenced.
This was associated
with
clearing
of
varicella
lesions and decreased
hepatosplenomegaly
and lymphadenopathy.
Over the next month,
clinical well-being
was maintained,
but the white cell count increased
steadily
despite
increased
dosage
of busulphan
to 4 mg daily.
Five weeks after initial presentation,
acute blastic transformation occurred,
with
recurrence
of lymphadenopathy
and hepatosplenomegaly.
Laboratory
data are
again shown in Table 1.
Treatment
was changed
to cyclophosphamide,
vincristine,
cytosine
arabinoside,
and prednisolone;
initial
improvement
occurred
until
profound
neutropenia
and recurrence
of blasts
supervened
10 wk after first presentation.
Treatment
was again changed
to 6-mercaptopurine,
cytosine
arabinoside,
daunorubicin,
and
L-asparaginase.
Good clinical
and hematological
improvement
resulted,
and the patient
has been
maintained
well on this regime for 7 mo.
MATERIALS
Cytogenetic
AND
METHODS
Studies:
Peripheral
blood
leukocytes
were cultured
with phytohemagglutinin
and harvested
essentially
according
to the method
of Arakaki
and Sparkes,18
while the direct
bone marrow
preparation
followed
that of Lam-Po-Tang.’9
A modification
of the method
of Hsu and Kellog2#{176}was
employed
for study
of skin fibroblasts.
Staining
for quinacrine
mustard
fluorescence
used the
procedure
of Caspersson
et al.21’22
Agar
Culture:
Washed
leukocytes
were cultured
at concentrations
of 1 X i#{248}to 2 X i05 cells/mi
in modified
Eagle’s minimal
essential
medium
containing
0.3%
agar.
The
technique
of agar culture
has been
described
in detail elsewhere.7
Cultures
were stimulated
by feeder layers containing
1 X 106 normal human
peripheral
blood
leukocytes
in 1 ml of 0.5% agar medium.8
The cultures
were incubated
at 37#{176}C
in 10% CO2 in air for 7-10 days and scored
at x 25 for incidence
of colonies
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CLONAL
ORIGIN
OF
CML
Table
1.
17
Hematological
and
Bone
Investigation
Hemoglobin
WCC
Marrow
Chronic
(g/100
Results
Phase
ml)
Acute
Phase
6.5
(perI)
8.1
61,800
124,000
Blasts
3%
32%
Premyelocytes
13%
4%
Myelocytes
22%
9%
Metamyelocytes
15%
13%
Band
12%
10%
forms
Neutrophils
2%
4%
Eosinophils
0
0
Basophils
Lymphocytes
Monocytes
Platelets
Bone
0
0
32%
25%
1%
(per I)
marrow
133,000
aspirate
7.4%
18.6%
79.2%
3.6%
Neutrophil
myelocytes
8.0%
2.0%
Neutrophil
metamyelocytes
8.6%
2.6%
Neutrophil
band
9.4%
3.0%
Neutrophil
polymorphs
5.8%
0.6%
Total
forms
eosinophils
Basophils
Lymphocytes
Monocytes
Reticulum
cells
Neutrophil
than
8.0%
0%
0
1.0%
Decreased
alkaline
cells)
was performed
cytocentrifuge
0%
1.0%
phosphatase
Decreased
0
muramidase
40
0%
1.2%
12.2%
Megakaryocytes
Serum
0.4%
27.4%
0%
Erythroblasts
(greater
3%
25,000
Myeloblasts
Premyelocytes
tion
Aspirate
16
60 pg/mI
and at X 40
on orcein-stained
preparations
of
cell
for
incidence
individual
of 3-40
cells.
and
clusters
of clusters
colonies
suspensions
62 pg/mI
prepared
by dispersion
Morphological
and
on
investiga-
Giemsa-stained
of pooled
colonies
and
clusters.
Cytogenetic
Analysis
Cytogenetic
during
incubation,
studies
the chronic
and
of Colonies
were
performed
and acute
3 hr
later
phase.
individual
and
on
Clusters:
agar
Colcemid
colonies
cultures
(0.2 jsg/ml)
and
clusters
of
peripheral
was added
were
removed
blood
leukocytes
to cultures
with
after
obtained
6-10
a micropipette
days
and
approximately
100 colonies
pooled
and dispersed
by repeated
pipettings.
The cell suspension
was processed
for metaphases
by the technique
of Moore and Metcalf.16
insufficient
metaphases
were obtained
from individual
colonies
for single-colony
typing.
Extensive
proliferation
of normal
and leukemic
marrow
cells has been reported
in liquid cultures
stimulated
by sources
of colony-stimulating
factor.23
Aye et al.24 used this technique
for
cytogenetic
analysis
of peripheral
blood cells from patients
in acute transformation
and reported
that aneuploid
cells present
in direct marrow
preparations
were also prevalent
in culture
after 10
days and that the proliferation
in vitro appeared
to be specific
for the leukemic
population.
in order
to complement
the agar culture
cytogenetic
analysis,
1-10 X 106 peripheral
blood
leukocytes
obtained
from our patient
in both the chronic
and acute phase were suspended
in fully
supplemented
Eagle’s
medium
and established
in Marbrook
culture
flasks25
in the presence
of
human
leukocyte-conditioned
medium
as a source
of colony-stimulating
factor.
Cytogenetic
analysis was performed
on the liquid cultures at 6-10 days incubation.
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18
MOORE
Neutral
Density
Peripheral
ml
of
leukocytes
serum
preparation
AL.
Separation:
blood
bovine
ET
of
obtained
albumin
the
in both
(BSA),
albumin
pH
5.1,
the chronic
269
and
details
of
centrifuged
at
3500
and acute
phase
and
density
1.062
been
described
milliosmolar
the
conditions
of
have
were
dispersed
in 3-5
g/cu
cm.
in
The
detail
elsewhere.26’27
The
cell
1.062
(<
suspension
gm/cu
was
cm)
and
the
The
density
distribution
of
the
population
less
than
Tritiated
The
dense
Thymidine
protocol
high-density
colony-
cell
and
1.062
g for
pellet
10
cluster-forming
g/cu
mm.
were
The
low
washed,
cells
density
counted,
was
supernatant
and
expressed
cells
cultured
as the
in agar.
percentage
of
cm.
“Killing”
of
Iscove
et
al.28
was
used
to
assess
the
proportion
of CFCs
in DNA
synthesis.
Peripheral blood leukocytes (4 x 106) were incubated
for 20 mm at 37#{176}Cin 1 ml of balanced
salt
solution (Eisen’s BSS) containing either 4OpCi of tritiated thymidine (H3TdR,
specific activity
16 Ci/mmole,
washes
with
Reduction
Radiochemicai
BSS
containing
in
H3TdR
colony-
exposed
Four
or
Amersham)
thymidine,
cluster-forming
cells and the cold
Muramidase
Serum
Centre,
cold
or 20 pg of unlabeled
thymidine.
Following
three
cells were
counted
and agar
cultures
established.
capacity
thymidine
was
assessed
by
comparison
of
cultures
from
controls.
Assay
muramidase
dilutions
a reference
levels were determined
of purified
egg
white
by
muramidase
the agar plate
method
(Sigma
Chemical
Co.,
of Osserman
and Lawlor.29
St. Louis,
Mo.) were used
as
standard.
RESULTS
Cytogenetic
analysis
during
the chronic
phase
and skin fibroblasts
revealed
two cell lines
46 XY/47
XYY with the 47 XYY lineage
of both
indicating
peripheral
blood
a constitutional
predominating
(Table
2).
preparations
demonstrated
in addition
a third 46XY
line including
which predominated
in both the chronic
and acute phase.
Quinacrine
karyotypes
22 while
mustard
fluorescence
since the Ph’
the cells with
of
the
two
abnormal
chromosome
showed
the
47 chromosomes
contained
cell
pale
lymphocytes
mosaic
a Ph’
lines
state
Direct
of
marrow
chromosome,
clearly
defined
the
fluorescence
of chromosome
two Y chromosomes
with the
characteristic
intense
fluorescence
of the distal portion
of the long arm.22’3#{176}
Agar culture
studies
revealed
that colonyand cluster-forming
cells were greatly
increased
in incidence
in the peripheral
blood during
the chronic
phase, a phenomenon
observed
in typical
Ph’ positive
CML (Table
3). Colonies
differentiated
to mature
neutrophils,
transition
tures.
but macrophages
was not observed
Colonies
developing
were present
at 7 days of culture.
in normal
marrow
cultures
but
during
the
2.
Table
chronic
phase
Cytogenetic
smaller
than
macrophage
CML culgenerally
Analysis
Total
No. of
Metaphases
Phase
were
This early
characterized
% Distrib
46
XV,
Ph’
ution
of Karyotypes
Chronic
Blood’
100
0
1
Chronic
Marrow
38
55
8
37
Chronic
Skin
30
0
10
90
Acute
Blood’
30
0
0
100
Acute
Marrow
30
83
7
10
mutated
cultures.
XV
XYV
Scored
‘PHAsti
46
47
Tissue
99
ob-
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CLONAL
ORIGIN
OF
Table
3.
19
CML
In Vitro
Culture
Results
Acute
on Peripheral
and
Chronic
NP.
Clusters/2X
Colony-forming
cell
density
(% < 1.062
Cluster-forming
(% < 1.062
cell
9/cu
Phase
0
1800
Blood’
Chronic
Phase
386
i05
in the
CML
Acute
Phase
x i0
Leukocytes
Blood
Chronic
Colonies/2
Blood
Phase
Acute
Normal
Phase
Blood’
20-3000
0-4
50-5000
0-6000
115
0-0.1
1-10
96
-
25-100
26-95
0.1-10
95
92
20-100
26-95
0.1-10
-
0-35
0-35
35-50
0-35
0-35
35-50
cm)
density
g/cu cm)
Colony-forming
by H3TdR
cells % killed
20
Cluster-forming
cells % killed
0
10
by H3TdR
Cytogeneticanalysisof
agar
46 XV
Ph1
(15)t
46XY
Ph1
(5)
Ph’
Ph’
-
46XY
Ph1
(3)
46XY
Ph1
(6)
-
-
-
culture
Cytogenetic
analysis
of liquid
47
XYY
(23)
47 XYY
(6)
cuIture+CSF
‘Results
on
other
Values
represent
normal
subjects.
tNumber
ICSF
,
CML
or normal
the range
subjects
observed
in parenthesis
refers to number
colony-stimulating
from
Moore
in 44 patients
with
et al.13”4
CML
of metaphases
and unpublished
in acute
and
chronic
observations.
phase
and
in 130
scored.
factor.
served
in either
normal
or CML cultures.
Subsequent
agar culture
of peripheral
blood
during
the acute phase and at a later stage following
therapy
showed
complete
loss of
colony
formation
with
production
of small,
poorly
differentiated
clusters
of 3-20
cells (Table
3). Density
separation
of colonyand cluster-forming
cells showed
that the
great majority
were of abnormal
light buoyant
density
both in the chronic
and acute
phase
(Table
3).
This
low-density
CML and
peripheral
was
orders.’3”4
termined
The proliferative
by the thymidine
in DNA
phase
blood
synthesis
(Table
Cytogenetic
agar culture
metaphases
peripheral
stimulate
46 XY,
markedly
distribution
different
of normal
was
from
subjects
status
“killing”
significantly
was
of both
technique
lower
than
analysis
revealed
colonyindicated
normal
and cluster-forming
that the proportion
in both
the
of leukemic
colonies
and clusters
developing
solely 46 XY, Ph’ metaphases
and neither
with
chronic
or
dis-
cells deof cells
and
acute
in peripheral
blood
46 XY nor 47 XYY
were
detected
in either
the acute
or chronic
phase.
Liquid
cultures
of
blood
leukocytes
in the presence
of human
leukocyte-conditioned
media to
granulocytic
proliferation
showed
a mixed
population
of 47 XYY
and
Ph’
positive
metaphases
at 7-10
days
transformation
HLA antigen
responsible.
were
Liquid
cultures
peripheral
blood
leukocytes
obtained
riched
for leukemic
cluster-forming
metaphases.
of all patients
3).
system
indicated
that lymphocyte
proliferation
and that soluble
Cytogenetic
characteristic
density
distribution
of CFCs in marrow
or patients
with nonleukemic
hemopoietic
the
analysis
of these
cultures
established
during
cells
after
of culture.
Further
from
a low-density
the acute phase. This
and greatly
depleted
7-9
investigation
of this
was occurring
in addition
to myeloid
in the human
CSF source
was probably
days
revealed
only
population
of
population
was enof lymphocytes.
46 XY, Ph’
positive
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20
MOORE
ET
AL.
DISCUSSION
There
can
be no doubt,
and
examination,
CML
from
at
CML
and
lymphocyte
both
the
morphological
differences
acute
transformation.’6
and bone
marrow
and
fluorescence
characteristics.
Agar
culture
and
by
studies
at the time
differentia-
density.
Subsequent
culture
studies
were consistent
with
prophase with loss of colony-forming
capacity
and the development
cell clusters.
The reduced
size of colonies
seen in the chronic
differentiated
cultures
blood
that this patient
was suffering
interest
was the coexistence
of
from this patient
showed
all the characteristics
ofCML
with abnormalities
in CFC incidence,
proliferation,
tion,
and buoyant
gression
to an acute
poorly
findings,
Ph’ chromosome
of outstanding
for 46 XY/47
XYY
as demonstrated
in skin fibroblast
Identification
of the Y and Ph’ chromosomes
was facilitated
peripheral
blood
of first
investigation
phase
of the clinical
of the
A finding
presentation.
mosaicism
cultures.
of
of
on the basis
presence
of this patient
has been
observed
frequently
to precede
clinical
onset
of
was found
only in the 46 XY cell line during
both chronic
no further
cytogenetic
evolution
was associated
with acute
transformation.
During
the chronic
phase
Ph’ positive
metaphases
comprised
only
55%, and the majority
of Ph’ negative
metaphases
were of the 47, XYY type. This
may
indicate
that
the capacity
of the leukeniic
population
to suppress
normal
hemopoiesis
was exerted
more effectively
against
the 46 XY line. However,
the nature
The Phtm chromosome
and acute
phases,
and
of the
mosaicism
in the
tissues
somatic
studied.
patient
The
indicated
percentage
a preponderance
of Ph’
positive
of 47
cells
XYY
increased
cells
in the
in the
marrow
during
acute transformation
but despite
heavy marrow
infiltration
by leukemic
blasts,
17%ofPh’
negative
metaphases
were still present.
The coexistence
of three different
cell lines in this patient
prompted
us to undertake
further
functional
tests to unequivocally
determine
the origin of the Ieukemic
cell line.
Cytogenetic
with
analysis
ported,
sition
cultures
only
of the
of the
total
role
functionally
colony
of
the
normal
constitution
cell
46
observation
of
suggested.
leukemic
whelmingly
cytogenetic
Density
Our
studies
in a low-density
progenitor
of 47,
are
devoid
of
46
XY or 47
XYY and 46, XY, Ph’
to
with
simultaneous
normal
lymphoid
in the circulation,
the
myeloid
compo-
XYY
of
that
cytogenetic
enrichment
iii liquid
cultures
suggests
that this
as Aye et al.24
proliferation
of both
cells. The latter
were overwhich
was in accord
with the
for
and
of
soluble
leukemic
subsequent
proliferation
solely
in unfractionated
presence
cells
cultures.
of lymphocytes,
most
the
sup-
analysis
provides
confirmation
process
and indicates
of colony-stimulating
factor
for leukemic
cell proliferation
extensive
revealed
the
transformation
due
cells
consistent
and
stimulated
leukemic
population
tion of lymphocyte
probably
of cytogenetic
cells
were
in the circulation.
produced
region
time
progenitor
This observation
in the leukemic
XY, Ph’)
constitution
on PHA
populations
population.
clone
observations
separation
of
leukemic
were still of the immature
dividing
closely
reflected
the cytogenetic
proliferation
myeloid
(46
of 47 XYY
proliferation
the colonies
compartment
stimulated
by human
leukocyte
sources
system
does not appear
to be as specific
have
the
acute
At the
XY Ph’
present
not
and
metaphases.
granulocytic
were
in which
chronic
46 XY Ph’
cell types within
hence
the mitotic
unique
The
agar
typical
revealed
predominant
series,
and
the
of
characteristics
HLA
cluster-forming
liquid
culture
cells
of this
of 46 XY, Ph’ cells. The inducleukocyte
liquid
cultures
was
antigen
in
the
crude
human
From www.bloodjournal.org by guest on December 22, 2014. For personal use only.
CLONAL
ORIGIN
leukocyte
OF
source
of lymphocyte
There
group
normal
CML
of colony-stimulating
been
have
debate
produced
conflicting
clonal
but
the
Further
Tough
possibility
antigens
origin
results
is not
by
factor,
by leukemia-specific
on the
chromosome
is incorrect.5’3’
been provided
has
21
transformation
has
X
CML
of CML
which
since
suggested
of autostimulation
cannot
be excluded.
studies
using
that
the Xg blood
either
the Xg locus of a
the single clone theory
of
subject
to inactivation
or that
evidence
et al.,3
which conflicts
with the clonal nature
of CML
who described
a patient
with CML and clinical
and cytogenetic
features
of a Klinefelter’s
mosaicism.
In this patient
the Ph’ chromosome was detected
in both
the 46 XY and 47 XXY populations.
Since
skin fibroblasts were solely 47 XXY it is probable
that the mosaicism
was restricted
to the marand
row
may
have
occurred
in a stem
line
subsequent
of a 47 XXY,
to the emergence
clone.
Strong
evidence
for the
genetic
studies
since females
of G-6PD
expressed
evidence
the
of
felter’s
mosaic
only
one
uniclonal
phenotype
origin
CML
with
uniclonal
origin
with CML and
with
of CML has
heterozygosity
in the leukemic
of CML
was
restrictions
also
of
been
for
population.3
presented
the
provided
by enzyme
the A and B subtypes
Ph’
Convincing
in a report
chromosome
of a Kline-
to
the
XY
46
cell line.4
In our patient
mosaicism
for 46 XY/47
XYY was clearly shown, both in skin flbroblast and blood
lymphocyte
cultures,
and the restriction
of the leukemic
population
to the 46 XY, Ph’ line provides
further
confirmation
of the uniclonal
origin of CML.
The coexistence
would
suggest
that
of two such rare disorders
as CML and sex chromosome
the latter
state carries
a high risk of further
cytogenetic
and emergence
of the Ph’
chromosome
mosaicism
evolution
abnormality.
ACKNOWLEDGMENT
The
authors
Hospital,
assistance,
would
like to
thank
Mrs.
D. Muckniki,
Melbourne
for initiating
skin fibroblast
and Mrs. N. Williams
for his guidance
Pathology
Department,
Royal
Women’s
cultures,
Mrs. J. Yeats for her excellent
in the density
separation
procedures.
technical
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From www.bloodjournal.org by guest on December 22, 2014. For personal use only.
1974 43: 15-22
Evidence for the Clonal Origin of Chronic Myeloid Leukemia From a Sex
Chromosome Mosaic: Clinical, Cytogenetic, and Marrow Culture Studies
M. A.S. Moore, H. Ekert, M. G. Fitzgerald and A. Carmichael
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