CLINICAL AND LABORATORY OBSERVATIONS
A Boy With Acute Lymphoblastic Leukemia Acquired
Clonal and Nonclonal Cytogenetic Abnormalities
Including del(7q) and del(20q) Without Clinical
Evidence of Disease After Sex-mismatched Cord
Blood Transplantation
In-Suk Kim, MD, PhD,* Hee-Jin Kim, MD,* Keon-Hee Yoo, MD, PhD,w
Ki-Woong Sung, MD, PhD,w and Sun-Hee Kim, MD, PhD*
Summary: An 8-year-old boy was diagnosed with precursor B-
cell acute lymphoblastic leukemia. After intensified chemother-
apy, he underwent sex-mismatched allogeneic cord blood
transplantation. Postcord blood transplantation cytogenetic
studies revealed engraftment failure evidenced by switching into
the recipient type (XY), and, notably, various complex
chromosomal aberrations in the recipient cells. Nonclonal and
clonal aberrations including deletions of 7q and 20q were
persistently observed. Nonetheless, the patient was clinically
stable without evidence of marrow dysplasia or leukemic cells.
Del(7q) and del(20q), 2 recurrent chromosomal aberrations in
myeloid neoplasia, might represent underlying genomic instabi-
lity in this patient, not the direct culprits of dysplasia or
leukemogenesis.
Key Words: acute lymphoblastic leukemia, unrelated cord blood
transplantation, graft rejection, chromosomal aberrations,
complete remission, genomic instability
(J Pediatr Hematol Oncol 2006;28:540–543)
S tem cell transplantation (SCT) such as bone marrow
transplantation (BMT) or cord blood transplantation
(CBT) has been used successfully for the treatment of
childhood acute lymphoblastic leukemia (ALL); however,
disease relapse and secondary malignancies after SCT
have remained major challenges.1 Both chemotherapy
and radiation for conditioning before SCT are thought to
be the causes of genomic instability and to produce
different types of chromosomal aberrations in bone
marrow cells, which may lead to the development of
Received for publication February 7, 2006; accepted May 31, 2006.
From the Departments of *Laboratory Medicine and wPediatrics,
Samsung Medical Center, Sungkyunkwan University School of
Medicine, Seoul, Korea.
Reprints: Sun-Hee Kim, MD, PhD, Prof, Department of Laboratory
Medicine, Samsung Medical Center, Sungkyunkwan University
School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul, Korea
135-710 (e-mail: sunnyhk@smc.samsung.co.kr).
Copyright r 2006 by Lippincott Williams & Wilkins
540
secondary malignancies.2–4 Previous reports on cytoge-
netic analyses after SCT have shown that some patients
had random or clonal chromosomal aberrations not
observed in the leukemic cells, and especially those
reported in therapy-related myeloid disorders, such as
deletion of the long arm of chromosome 7 or chromo-
some 20, were associated with peripheral cytopenia,
morphologically recognizable dysplasia in hematopoietic
precursors, or the development of secondary malignan-
cies.3,5,6
Here we describe an 8-year-old male patient with
precursor B-cell ALL, who has shown complex cytoge-
netic aberrations including persistent clonal del(7q) and
del(20q) as well as appearance and disappearance of
random, nonclonal variable aberrations after CBT and
subsequent graft rejection. Despite complex chromosomal
aberrations on cytogenetic analyses, the patient has been
in complete remission (CR) without any evidence of
dysplasia in hematopoietic precursors or peripheral
cytopenia. It was suggested that del(7q) and del(20q),
along with other complex chromosomal aberrations,
might represent underlying genomic instability in this
patient, rather than being the direct culprits leading to
dysplastic phenotypes or leukemogenesis.
CASE REPORT
An 8-year-old boy was admitted because of pallor and
fever. Initial laboratory tests showed Hb 6.3 g/dL, white blood
cell count 91.22  109/L, and platelet 42  109/L. Peripheral
blood smear revealed that 88% of the white blood cells were
blasts with a lymphoid appearance, and the bone marrow
aspirate smear revealed the blasts were counted at 96%. Flow
cytometric analyses showed that these blasts were CD10+,
CD19+, HLA-DR+, and CD34+, indicating precursor B-cell
ALL. There were no physical features indicative of a congenital
genomic instability syndrome. Cytogenetic analysis with bone
marrow cells revealed 3 metaphases with hyperdiploidy (51+)
as 63B65,XY,+X,+2,+3,+5,+6,+7,+8,+10,+11,+12,+13,
+14,+15,+16,+17,+19,+21,+mar[cp3] (Table 1). We per-
formed fluorescence in situ hybridization (FISH) analyses
for the BCR/ABL (LSI BCR/ABL Dual Color, Dual Fusion
Translocation Probe, Vysis, Downers Grove, IL), TEL/AML1
J Pediatr Hematol Oncol  Volume 28, Number 8, August 2006
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2006 Lippincott Williams & Wilkins
TABLE 1. The Cytogenetic Study Results of the Patient Showing Various Complex Chromosomal Aberrations After Sex-mismatched CBT and Subsequent Graft
Failure
Time post-CBT
At initial Dx with ALL
First CR after induction CTx
Pre-CBT work-up
Post-CBT no. 1 (35 d)
Post-CBT no. 2 (100 d)
Post-CBT no. 3 (7 mo)
Post-CBT no. 4 (9 mo)
Post-CBT no. 5 (11 mo)
Post-CBT no. 6 (15 mo)
Post-CBT no. 7 (19 mo)
Post-CBT no. 8 (20 mo)
Post-CBT no. 9 (22 mo)
Post-CBT no. 10 (25 mo)
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Volume 28, Number 8, August 2006
FISH Studies for p16
Karyotype of Bone Marrow Cells Comment Deletion or X/Y
63-65,XY,+X,+2,+3,+5,+6,+7,+8,+10,+11,+12,+13, Hyperdiploid (51+) FISH, p16: deletion in 95%
+14,+15,+16,+17,+19,+21,+mar[cp3]
46,XY[20] — FISH, p16: deletion in 0%
46,XY[9] — FISH, p16: deletion in 0%
46,XY[20] (1) Graft failure FISH, X/Y: XY in 100%
(2) 9 metaphases showed nonclonal chromosomal
aberrations including 1p22 rearrangements
46,XY[6] — FISH, X/Y: XY in 100%
46,XY,t(2;8)(p21;q24.3),t(3;14)(p25;q22),t(11;14)(q13;q32)[3]/46, 7 metaphases showed nonclonal chromosomal FISH, X/Y: XY in 100%
XY,t(1;15)(p22;q15)[2]/46,XY[15] aberrations
46,XY,t(2;11)(p11.2;p15),t(10;14)(q22;q22)[6]/46, 4 metaphases showed nonclonal chromosomal FISH, X/Y: XY in 100%
XY,del(7)(q22q34)[4]/46,XY[10] aberrations
46,XY[20] 10 metaphases showed nonclonal chromosomal —
aberrations including del(7)(q32) and del(7)(q22)
46,XY,del(7)(q22q34)[3]/46,XY[13] 6 metaphases showed nonclonal chromosomal —
aberrations including del(20)(q11.2)
46,XY,del(7)(q22q34),t(9;12)(p13;q13),t(11;19)(q13;p13.1), 12 metaphases showed nonclonal chromosomal FISH, p16: deletion in 0%
inv(13)(q12q32),del(20)(q13.1)[5]/46,XY[15] aberrations including del(7)(q22) and del(7)(q22q32)
46,XY,del(7)(q22q34),t(9;12)(p13;q13),t(11;19)(q13;p13.1), 8 metaphases showed nonclonal chromosomal —
inv(13)(q12q32),del(20)(q13.1)[9]/46,XY[11] aberrations including del(7)(q22)
46,XY,del(2)(q21q31),add(11)(q21),add(14)(q32), 3 metaphases showed nonclonal chromosomal FISH, X/Y: XY in 100%
Persistence of del(7q) and del(20q) in a Boy
t(15;18)(q23;q23)[3]/46,XY[5] aberrations including del(7)(q22q34) and FISH, p16: deletion in 0%
del(20)(q13.1)
46,XY,del(7)(q22q34),t(9;12)(p13;q13),t(11;19)(q13;p13.1), 5 metaphases showed nonclonal chromosomal FISH, p16: deletion in 0%
inv(13)(q12q32),del(20)(q13.1)[5]/46,XY[15] aberrations
With ALL After CBT
Kim et al
(LSI TEL/AML1 ES Dual Color Translocation Probe, Vysis)
and MLL (LSI MLL Dual Color, Break Apart Rearrangement
Probe, Vysis) rearrangements along with p16 deletion (LSI p16
SpectrumOrange/CEP 9 SpectrumGreen Probe, Vysis). For
each probe set, 200 interphase nuclei were analyzed. FISH
signals from BCR/ABL were within reference ranges, whereas
TEL/AML1 FISH showed 69.5% of interphase cells with 4
AML1 and 3 TEL signals and 27.0% cells with 3 AML1 and 3
TEL signals. MLL FISH showed 94.5% cells with 3 MLL
signals. These findings were consistent with hyperdiploidy (51+)
observed on the cytogenetic study involving chromosomes 12
(TEL), 21 (AML1), and 11 (MLL). On the other hand, FISH for
p16 deletion showed 95% cells with homozygous deletion of the
p16 signals with the 2 copies of centromeres retained, indicating
that most of the leukemic cells harbored interstitial p16 deletion
and that p16 FISH could be used as a leukemia-specific follow-
up marker. The patient received intensified induction che-
motherapy and achieved CR on d28. After consolidation
chemotherapy, he received CBT from an unrelated female
donor. Pre-SCT cytogenetic analysis of bone marrow cells
showed 46,XY[20], and p16 FISH showed 0% cells with p16
deletion (Table 1). The HLA of the donor and the patient was
genotypically A- and DR-mismatched (patient: HLA-A 02/29,
-B 4006/51, -DR1201/1405, and donor: HLA-A 02/24, -B 4006/
51, -DR1201/1403). The conditioning regimen consisted of
cytarabine (3 g/m2 twice a day for 3 d) and fractionated total-
body irradiation (2 Gy twice a day for 3 d), and the number of
infused donor marrow cells was 2  107/kg. Prophylaxis against
graft-versus-host disease consisted of cyclosporine and methyl-
prednisolone. Granulocyte-colony stimulating factor was given
posttransplant for 3 weeks. The hematologic recovery was
achieved as follows: the time for the absolute neutrophil count
to be over 0.5  109/L was d25 from CBT, for the reticulocytes
to be over 2.0% was d28, and for the platelet count to be over
50  109/L was d33. On the other hand, the first bone marrow
study after CBT (d35) indicated graft engraftment failure with
autologous hematopoietic recovery: FISH analyses for X/Y
(CEP X/Y DNA Probe, Vysis; 500 interphase nuclei were
analyzed) on bone marrow cells showed that 100% of cells had
XY, the recipient type. The HLA mismatch at the A and DR
loci was thought to be the cause of graft rejection. In line with
the FISH result, cytogenetic analysis revealed all 20 metaphases
with XY (Table 1). Of note, 9 metaphases had random,
nonclonal cytogenetic aberrations. A series of follow-up
cytogenetic studies (post-CBT no. 1 to 10 during the 25-mo
follow-up period) showed appearance and disappearance of
various, complex chromosomal aberrations. From post-CBT
no. 3 (7 mo), we could observe some clonal changes occurring in
3 or more metaphases, and particularly, from post-CBT no.
4 (9 mo) and then on, del(7q), with or without del(20q)
was consistently observed (Table 1, bold). However, the
concurrent bone marrow examinations still revealed normal
hematopoietic precursors without evidence of dysplastic
features, and his clinical course has been stable with normal
blood cell counts until the most recent outpatient follow-up
27 months after CBT.
DISCUSSION
Although cytogenetic aberrations after SCT typi-
cally occurs in the form of continuous appearance of
identical clones or short-term appearance of random
changes, there are a limited number of reports on cases
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J Pediatr Hematol Oncol  Volume 28, Number 8, August 2006
with continuously changing chromosomal aberrations
after allogeneic SCT.7–9 Lin et al7 described a child with
precursor B-cell ALL with repeated appearance and
disappearance of different kinds of clonal cytogenetic
abnormalities in the residual recipient cells on a series of
bone marrow studies during the 5.5-year follow-up period
after allogeneic BMT. More recently, 2 reports from
Japan described 2 pediatric patients with precursor B-cell
ALL with numerous nonclonal chromosomal aberrations
arising in the residual recipient hematopoietic cells after
allogeneic BMT.8,9 The patient reported by Yoshihara et
al8 showed abnormal karyotypes of the recipient origin
after BMT with the chromosome band 1p22 being the
most frequently affected site. The chromosome band 1p22
was reported to be the target site of chromosomal
rearrangement in patients after radiotherapy and in in
vitro radiation experiments.10,11 Our patient also showed
nonclonal rearrangements involving the 1p22 band
(Table 1). Because donor leukocyte infusions were
performed considering the potential risk of late graft
failure and/or secondary leukemia, which resulted in
complete chimera, the long-term clinical significance of
the random chromosomal aberrations in that case could
not be assessed. The patient reported by Masuko et al9
developed random chromosomal aberrations 1 month
after SCT, and stable clonal changes including del(20q)
emerged 3 years after BMT and was still observed 8 years
after BMT despite the stable CR status of the patient. In
our patient, the appearance and disappearance of various
types of nonclonal cytogenetic abnormalities indicated
that none of the cells had acquired growth advantages,
whereas the persistent clones with del(7q), with or
without del(20q), could have been produced by the self-
renewing hematopoietic stem cells. However, because we
did not perform cytogenetic analyses on peripheral blood
cells with or without phytohemagglutinin activation, the
self-replicability of the bone marrow cells with those
cytogenetic aberrations could not be demonstrated.
Including our case, all 4 cases were young patients (age,
2.3 to 16 y) with precursor B-cell ALL from Asian
countries, received high-dose cytarabine and total body
irradiation for conditioning, experienced graft rejection,
and the chromosomal aberrations occurred in the
recipient nonleukemic cells. In particular, we could
demonstrate the absence of leukemic cells in bone marrow
by employing p16 FISH as the leukemia-specific follow-
up marker.
The significance of cytogenetic abnormalities not
related to the initial leukemic clone in the absence of
dysplasia or secondary hematologic malignancy after
CBT and the mechanism by which secondary hematologic
malignancy develops from the clone with cytogenetic
aberrations are still not clear. In our patient and the
patient reported by Masuko et al9 as well, the chromo-
somal aberrations known to be associated with de novo
or therapy-related myelodysplastic syndrome or acute
myeloid leukemia such as del(20q) and del(7q) might
represent the underlying genomic instability in the
recipient cells caused by chemotherapy or irradiation,
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J Pediatr Hematol Oncol  Volume 28, Number 8, August 2006
and further genetic events are needed to develop
myelodysplastic syndrome or acute myeloid leukemia.
More cases and long-term follow-up data are needed to
understand the significance of the ‘‘silent’’ chromosomal
aberrations after CBT.
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