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  Table of Contents    
CASE REPORT  
Year : 2021  |  Volume : 64  |  Issue : 4  |  Page : 820-823
A case of double positive myeloproliferative neoplasm: A diagnostic and therapeutic challenge


1 Department of Hematopathology, AmPath, Hyderabad, Telangana, India
2 Department of Hemato-Oncology and Bone Marrow Transplant, American Oncology Institute, Hyderabad, Telangana, India
3 Department of Cytogenetics, AmPath, Nallagandla, Serilingampally, Hyderabad, Telangana, India
4 Department of Molecular Diagnostics, AmPath, Nallagandla, Serilingampally, Hyderabad, Telangana, India

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Date of Submission13-Aug-2020
Date of Decision12-Sep-2020
Date of Acceptance09-Dec-2020
Date of Web Publication20-Oct-2021
 

   Abstract 


Chronic Myeloid Leukemia, BCR-ABL1 positive (CML) is distinct from other myeloproliferative neoplasms (MPNs) as it is positive for the Philadelphia chromosome (Ph) with presence of BCR-ABL1 translocation that makes it responsive to targeted therapy with tyrosine kinase inhibitors (TKI). Distinctly there is another group of Ph-negative myeloproliferative neoplasms as polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET) and others that harbor an activating mutation in the Janus Kinase 2 gene (JAK2), i.e., JAK2 V617F mutation. BCR-ABL1 translocation and the JAK2 V617F mutation are generally considered disease defining and mutually exclusive due to diagnostic and therapeutic implications. We hereby present a rare case of MPN with coexistent expression of BCR-ABL1 translocation and JAK2 V617F mutation thus posing a challenge in diagnosis, treatment, and follow-up.

Keywords: BCR-ABL1, chronic myeloid leukemia, flow cytometry, myelofibrosis, JAK2 V617F

How to cite this article:
Shaikh AB, Aribandi A, Gupta A, Subramanian SK, Goyal M. A case of double positive myeloproliferative neoplasm: A diagnostic and therapeutic challenge. Indian J Pathol Microbiol 2021;64:820-3

How to cite this URL:
Shaikh AB, Aribandi A, Gupta A, Subramanian SK, Goyal M. A case of double positive myeloproliferative neoplasm: A diagnostic and therapeutic challenge. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Nov 28];64:820-3. Available from: https://www.ijpmonline.org/text.asp?2021/64/4/820/328587





   Introduction Top


Myeloproliferative Neoplasms (MPN) are clonal hematopoietic stem cell disorders characterized by proliferation of one or more of myeloid lineages. Chronic Myeloid Leukemia, BCR-ABL1 positive (CML) is a distinct MPN from commonly occurring entities as Polycythemia Vera (PV), Primary Myelofibrosis (PMF), Essential Thrombocythemia (ET), and other rarer ones. CML is characterized by proliferation of granulocytic component and characteristic translocation t(9;22) (q34;q11), which produces the Philadelphia (Ph) chromosome with formation of BCR-ABL1 fusion gene.[1] Majority of other Ph-negative MPNs harbor an activating mutation in the Janus Kinase 2 gene (JAK2 V617F). JAK2 V617F mutation is found in 95% of PV patients and 50% each of ET and PMF patients.[2] There are few case reports with both alterations in same patient.[3],[4],[5] We hereby present a rare case of MPN with coexistent expression of BCR-ABL1 and JAK2 V617F, highlighting the challenges in diagnosis, that have not been addressed yet, and discuss the strategies adopted for treatment with follow-up and possible pathogenesis.


   Case Report Top


A 45-year-old female presented with distended abdomen, breathlessness, and fever of two months duration. She was pale, had massive splenomegaly, but no icterus, pedal edema, hepatomegaly or lymphadenopathy. Complete blood counts (CBC) revealed hemoglobin of 8.5 gm/dl, hematocrit-25.7%, RBC count-3.53 × 106/μL, leukocyte count-14.3 × 103/μL and platelet counts-198 × 103/μL. Peripheral smear revealed leuko-erythroblastic blood picture with presence of microcytic hypochromic cells, tear drop forms, polychromatophils, nucleated RBCs, basophilia, myeloid shift to left and circulating blasts. Bone marrow aspirate was tiny particulate with low cellularity showing hypolobate, dysmorphic megakaryocytes, and 14% blasts. Flowcytometry on bone marrow aspirate showed 11% blasts that expressed bright CD34, moderate HLA-DR, CD33, dim CD38, CD13 and partially expressed dim CD7, while negative for CD10, CD19, CD22, cytoplasmic CD3, CD5, CD14, CD15, CD117, myeloperoxidase, CD56, CD56, CD64, CD36, CD11b, CD16, CD41 and CD61. Bone marrow biopsy showed thickened bony trabeculae with 60% intervening marrow cellularity with reduced erythropoiesis, markedly increased myelopoiesis, mild prominence of eosinophils and markedly increased megakaryopoiesis. Megakaryocytic clustering with presence of numerous atypical and dwarf megakaryocytes, prominence of blasts interstitially along with stromal changes in form of fibrosis, edema, sinusoidal dilation and intrasinusoidal hematopoiesis were also noted [Figure 1]a and [Figure 1]b. Reticulin stain showed grade 3 condensation of fibers with focal collagenization on Masson trichrome stain. Immunohistochemistry with CD34 and CD117 confirmed presence of around 12% myeloid precursors.
Figure 1: (a) Photomicrograph of the trephine biopsy showing markedly thickened bony trabeculae with reduction in marrow spaces and stroma showing fibrosis with dilated sinusoids. (Hematoxylin and eosin stain, 100×). (b) Photomicrograph of the trephine biopsy showing marked increase in megakaryocytes, with most of them appearing dysmorphic in form of micromegakaryocytes and dwarf forms. (Hematoxylin and eosin stain, 100×)

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Conventional bone marrow karyotyping revealed Philadelphia chromosome, i.e., 46, XX, t(9;22) (q34;q11.2), confirmed by fluorescent in-situ hybridization (FISH), with no additional chromosomal abnormalities. Qualitative PCR for BCR-ABL1 revealed e14a2 transcript [Figure 2]a. JAK2 V617F mutation was evaluated due to morphological suspicion of osteomyelosclerosis and detected by real-time allele-specific oligonucleotide PCR with an allele burden of 1.83% (Limit of detection at 0.5%) [Figure 2]b. This case was finally diagnosed as Chronic Myeloid Leukemia, BCR-ABL1 Positive with concomitant JAK2 V617F mutation (low allele burden), morphologically in transformation in form of osteomyelosclerosis and accelerated phase. Patient was treated with dasatinib (100 mg) and hydroxyurea. After three months, she achieved complete hematological response with clinical improvement in symptoms and regression of spleen with normalization of complete blood counts. Bone marrow examination showed blasts <5%, however, showed residual myelofibrosis. Molecular response was assessed using BCR-ABL1 quantification at intervals of every three months that did not reveal any residual disease. Last assessment was performed two years after the first diagnosis that showed no residual BCR-ABL1, however, JAK2 V617F mutation analysis revealed an allele burden of 4.69%.
Figure 2: (a) Digital image of agarose gel electrophoresis of multiplex reverse transcriptase Polymerase amplified product of BCR ABL run on a 2% w/v agarose gel, 3 volt/cm, stained with 1% ug/ml ethidium bromide. The DNA size marker is a commercial 50bp ladder (Thermo Scientific). The position of different products in the wells show the index case (Lane-7) positive for e14a2 (Lane 12: Index case housekeeping gene, Lane 50bp: 50 bp marker; Lane-1: positive control for e14a2 (384 bp), Lane -2: positive control for e13a2 (310 bp), Lane-3: negative control, Lane-13: Negative Control housekeeping gene). (b) Real Time ARMS PCR for JAK2 V617F showing amplification of both wild and mutant alleles (as marked). Known Negative Control, Positive Control and Commercial low positive control run with patient samples (not shown in the figure)

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   Discussion Top


The concomitant occurrence of JAK2 V617F mutation and BCR-ABL1 translocation is a rare event, although a few case reports and series of coexistence of these two mutually exclusive mutations have been published. Martin-Cabrera et al. reported the frequency of concurrent occurrence of these two mutations in MPNs to be 0.2% and Pieri et al. reported the incidence to be 2.55%. This difference was due to different cohorts used in these studies, while the former studied the incidence in all the cases suspected of over 10,000 MPN cases and the latter in 314 typical BCR-ABL1 positive CML.[6],[7] Among the reported cases, the patients either had pre-existing BCR-ABL1 positive CML and developed JAK2 V617F mutation while undergoing tyrosine kinase inhibitor treatment or developed BCR-ABL1 positive CML with a pre-existing JAK2 V617F mutation-positive MPN.[5] In very few cases, there was simultaneous occurrence of both JAK2 V617F mutation and BCR-ABL1 translocation.[3],[8]

Basis the presence of BCR-ABL1, we labeled our case primarily as BCR-ABL1 positive CML, as this distinction is critical due to therapeutic implications. The cases of CML with dual abnormalities presented in chronic phase and none of the cases in accelerated phase or blast crisis had JAK2 V617F mutation.[7] Our case had features of progression - fibrosis and accelerated phase. Whether the concomitant low allele burden JAK2 V617F mutation was responsible for the progression is not known and there is no mention of it in the literature to the best of our knowledge. Allele burden gives an estimate of disease burden and is best assessed by allele-specific real-time PCR. It is low (<10%) in 40% of cases of essential thrombocythemia and a higher burden indicates homozygosity or progression to myelofibrosis.[9] The only deduction that may be drawn is that it would have caused fibrosis, although many cases of JAK2 V617F positive MPN may not have fibrosis and vice-versa. Further analysis on other molecular abnormalities as TET2, IDH1, CBL, ASXL1, etc., have to performed to evaluate for the reasons for accelerated phase.

These cases pose two challenges - when to evaluate additionally for JAK2 V617F mutation in a case of CML as the further testing stops when BCR-ABL1 is positive and how to treat as there are no specific guidelines for treatment. Our case was worked up for both abnormalities due to clinical and morphological dilemma. Hussein et al. suggested that in a case of CML additional JAK2 V617F mutation testing be performed either when abnormal blood counts suggest imatinib therapy failure and the BCR-ABL1 is absent or the bone marrow histology reveals myelofibrosis and/or enlarged and clustered megakaryocytes either at presentation or during the course of disease.[10] From the therapeutic perspective in our case, the presence of BCR-ABL1 made the choice of TKI imperative with Dasatinib taking an upper hand as it presented in accelerated phase. Our case clinically improved and achieved complete molecular response with complete clearing of Ph-positive clone and whether adding another targeted drug as ruxolitinib would have made a difference in the clinical course or the clone size is debatable.

Various theories have been proposed for the simultaneous occurrence of these mutations, while some suggested origin in two different clones and others in the same clone.[3],[5],[6],[11],[12] Few suggested the theory of clonal evolution in which initially JAK2 mutation occurs followed by the BCR-ABL1 translocation.[11],[12] Other hypotheses suggest the presence of two independent clones each having BCR-ABL1 and JAK2 V617F mutation and sometimes with presence of subclones.[4],[10],[12] The non-dominant clone becomes detectable following the cytoreduction of the dominant clone as seen in our case, i.e., the JAK2 V617F positive clone persisted even after complete clearance of BCR-ABL1 positive clone.


   Conclusion Top


Double positive (BCR-ABL1 and JAK2 V617F) MPNs are rare and challenging with a distinct biological behavior, thus requiring further studies with larger cohorts to establish the incidence, criteria for further testing and the appropriate treatment.

Key points

  • Myeloproliferative neoplasms (MPNs) with coexistent expression of BCR-ABL1 and JAK2 V617F is a very rare entity that are not defined in WHO classification.
  • This entity poses challenges in making a diagnosis, selecting the best strategies for treatment, and follow-up, that have not been addressed yet.
  • Double positive MPNs have a distinct biological behavior that needs to be further understood better.


Acknowledgments

We would like to acknowledge Ms. Erusha and Ms. Eshwari from Department of Hematopathology for performing flow cytometry on this case, Mr. Prabhupad Rath and Mr. Prateek from the Department of Molecular Diagnostics for performing the molecular tests and also evaluating the primary results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vardiman JW, Melo JV, Baccarani M, Radich JP, Kvasnicka HM. Chronic Myeloid leukaemia, BCR-ABL1-positive. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, Revised. 4th ed. Lyon: PA: IARC; 2017. p. 30-6.  Back to cited text no. 1
    
2.
Carranza C, Tinti D, Herrera M, Rosales L, Villegas M, Silva G. Detection of Jak2 V617f mutation, secondary to the presence of Bcr-Abl1 translocation in a patient with chronic myeloid leukemia: Report of a case and review of the literature. Int J Genomic Med 2014;2:116.  Back to cited text no. 2
    
3.
Cambier N, Renneville A, Cazaentre T, Soenen V, Cossement C, Giraudier S, et al. JAK2V617F-positive polycythemia vera and Philadelphia chromosome-positive chronic myeloid leukemia: One patient with two distinct myeloproliferative disorders. Leukemia 2008;22:1454-5.  Back to cited text no. 3
    
4.
Bee PC, Gan GG, Nadarajan VS, Latiff NA, Menaka N. A man with concomitant polycythaemia vera and chronic myeloid leukemia: The dynamics of the two disorders. Int J Hematol 2010;91:136-9.  Back to cited text no. 4
    
5.
Zhou A, Knoche EM, Engle EK, Fisher DA, Oh ST. Concomitant JAK2 V617F-positive polycythemia vera and BCR-ABL-positive chronic myelogenous leukemia treated with ruxolitinib and dasatinib. Blood Cancer J 2015;5:e351.  Back to cited text no. 5
    
6.
Martin-Cabrera P, Haferlach C, Kern W, Schnittger S, Haferlach T. BCR-ABL1-positive and JAK2 V617F-positive clones in 23 patients with both aberrations reveal biologic and clinical importance. Br J Haematol 2017;176:135-9.  Back to cited text no. 6
    
7.
Pieri L, Spolverini A, Scappini B, Occhini U, Birtolo S, Bosi A, et al. Concomitant occurrence of BCR-ABL and JAK2V617F mutation. Blood 2011;118:3445-6.  Back to cited text no. 7
    
8.
Cappetta M, Pérez V, Zubillaga MN, Elizondo V, Manrique G, Prosper I, et al. Concomitant detection of BCR-ABL translocation and JAK2 V617F mutation in five patients with myeloproliferative neoplasm at diagnosis. Int J Lab Hematol 2013;35:e4-5.  Back to cited text no. 8
    
9.
Gong JZ, Cook JR, Greiner TC, Hedvat C, Hill CE, Lim MS, et al. Laboratory practice guidelines for detecting and reporting JAK2 and MPL mutations in myeloproliferative neoplasms: A report of the association for molecular pathology. J Mol Diagn 2013;15:733-44.  Back to cited text no. 9
    
10.
Hussein K, Bock O, Theophile K, Seegers A, Arps H, Basten O, et al. Chronic myeloproliferative diseases with concurrent BCR-ABL junction and JAK2V617F mutation. Leukemia 2008;22:1059-62.  Back to cited text no. 10
    
11.
Wang X, Tripodi J, Kremyanskaya M, Blouin A, Roda P, Hoffman R, et al. BCR-ABL1 is a secondary event after JAK2V617F in patients with polycythemia vera who develop chronic myeloid leukemia. Blood 2013;121:1238-9.  Back to cited text no. 11
    
12.
Bader G, Dreiling B. Concurrent JAK2-positive myeloproliferative disorder and chronic myelogenous leukemia: A novel entity? A case report with review of the literature. J Investig Med High Impact Case Rep 2019;7:1-5.  Back to cited text no. 12
    

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Correspondence Address:
Manu Goyal
HOD Hematopathology and Consultant Molecular Hematopathologist, AmPath, Nallagandla, Serilingampally, Hyderabad - 500 019, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_977_20

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