Pediatric acute myeloid leukemia patients with i(17)(q10) mimicking acute promyelocytic leukemia: Two case reports

INTRODUCTION

Chromosome i(17)(q10) abnormality is described as any unreasonable damage or breakage of the centromeres of chromosome 17, resulting in absence of the short arm and an iso-arm of the long arm[1]. Isochromosome 17 i(17)(q10) is mainly associated with chronic myeloid leukemia (CML)[2,3], myelodysplastic syndrome/myeloproliferative tumors (MDS/MPD)[4-6], and acute myeloid leukemia (AML)[6,7]. Genetic mutation analysis showed that 95% of patients with chromosome karyotype i(17)(q10) carried at least one mutation, and on average three mutations. The three most commonly mutated genes were(66%),(65%), and(48%)[8,9]. In acute promyelocytic leukemia (APL), chromosome karyotype i(17)(q10) was often accompanied by t(15;17) and PML-RARa fusion gene with an incidence of 1.9% and 4.1%, respectively[10,11]. APL children with i(17)(q10) have poor prognosis[12]. In a group study of 478 children with AML, chromosome karyotype analysis showed only one i(17)(q10) abnormality case, without morphological description and prognostic evaluation[13]. A 10-year-old African Black APL child carrying i(17)(q10) karyotype but without t(15;17) abnormality, who was in serious condition at admission, did not get tumor remission after treatment, and died within 2 wk[14]. A Chinese i(17)(q10) AML adult with a similar phenotype to APL was reported[15]. In the present case study, we treated 1 AML child with i(17)(q10) and 1 AML child with i(17)(q10) and (14)(p11) who had a phenotype similar to APL in our department. These two cases were investigated and followed up, and their clinical significance was discussed.

CASE PRESENTATION

Chief complaints

A 3-year-old boy of Han nationality, was admitted to the Pediatric Hematology Department of Xianyang Caihong Hospital, China on December 19, 2016. The boy had paleness and fever for more than half a month, as well as exophthalmos and pain in the right knee joint due to unknown reasons for two weeks.

露地栽植時，一般株行距為30×40cm，施入腐熟的有機肥，并施入過磷酸鈣和草木灰等含磷鉀成分高的肥料作基肥，栽植后將根莖壓緊，栽植后需澆透水。溪蓀鳶尾的生長旺盛期為6-8月，持續時間約為3個月，生長迅速，根系發達，形成了較完整的營養器官。生長旺盛期可追肥2次，每畝可追施尿素10-15kg、磷酸二銨5-10kg[3]。栽植后及時中耕除草，清除雜草時勿傷根系，根據地面情況一般每周澆水1次，保證正常生長。夏季地表的高溫高熱會灼傷苗木，可每周澆水2次，早晚進行適量噴水。生長后期從10月上旬至11月初，苗生長快速下降。期間適當少灌，每周澆水1次。做好植株安全越冬的工作，初冬澆1次封凍水。

1.校園環境方面。好的環境對于學生的學習與成長有著積極作用。為使學生更好地接受傳統文化，主動誦讀經典詩文，學校方面應加強校園文化建設。譬如在文化墻上手繪《弟子規》或者是《三字經》篇章，使其成為學生的行為準則：孝敬父母、尊師重道、團結友愛、積極進取。教學樓走廊墻壁上應掛詩詞名作，學校的廣播站應定期定時播放經典古詩文；在班級文化建設方面也應注重經典誦讀，班級中學習園地應不定時展示出學生關于經典詩文的繪畫、寫作及摘錄作品等。通過校園文化的建設，使整個校園充滿詩意，促進學生對古詩文的學習。

A 12-year-old Han boy was admitted to our hospital with a history of a pale complexion for one month and skin bleeding for 10 d.

He had a fever of 38.2 °C, moderate anemia, scattered red bleeding spots on the skin, protruded eyeballs, and no swelling of the superficial lymph nodes.Initial blood tests showed the following: Hb 75 g/L, white blood cell (WBC) count 5.82 × 10/L, and platelet (PLT) count 73 × 10/L.

History of present illness

當入庫貨物i目標貨位與出庫貨物n所在貨位同層，入庫貨物j目標貨位與出庫貨物m所在貨位同層(yi=yn≠yj=ym)時，

He had moderate anemia and bleeding spots on the skin and mucosa throughout the body. Initial blood test results showed the following: Hb 68 g/L, WBC count 17.53 × 10/L, and PLT count 60 × 10/L.

History of past illness

Bone marrow smear: Case 1 showed active bone marrow with nucleated cell hyperplasia. Case 2 originally had granulocyte at 1.0%, and abnormal early young granulocyte at 83.0% and 85.0%, respectively. The cytoplasm was bulky and filled with azure particles. Plasma particles were visible both inside and outside some cells, with less outside the cells. Round or oval nucleus, coarse chromatin, and indistinct nucleoli were observed. Acute promyelocytic leukemia is shown in Figure 1.

For case 2, the following mutation sites might be associated with the disease: (1) TAL1 (T-Cell Acute Lymphocytic Leukemia genemutation (NM_003189:exon6:c.821_822insGGGGGGGGGGGGGG:p.G274fs), with a mutation frequency of 44.2%; (2) TTN mutation in the titin gene (NM_001267550:exon96:c.C27746T:p.T9249M), with a mutation frequency of 53.5%; (3) PHLPP1 (PH Domain And Leucine Rich Repeat Protein Phospatase1) gene mutation (NM_19449:exon1: c.77_78insTCTGG:pA26fs), with a mutation frequency of 35.3%; (4) OR5B12 (Olfactory Receptor Family 5 Subfamily B Member 12) gene mutation (NM_001004733:exon1:c.597delT:p.199fs), with a mutation frequency of 83.5%; (5) DDX11 (DEAD/H-BOX Helicase 11) genemutation (NM_152438: exon7:c.G778A:p.R263Q), with a mutation frequency of 18.8%.

Personal and family history

He had been in good health condition, with no family history of inherited blood disorder, no history of tumor-associated genetic abnormalities, and no history of drug or food allergies.

There is no personal and family history.

Physical examination

Upon examination, he had a fever of 38.2 °C, moderate anemia, scattered red bleeding spots on the skin, protruded eyeballs, and no swelling of the superficial lymph nodes. On auscultation, his heart and lung were normal, and the liver and spleen were not examined.

He had moderate anemia and bleeding spots on the skin and mucosa throughout the body. Auscultation of the heart and lung showed no abnormalities. Subcostal areas of the liver and spleen were not examined.

Laboratory examinations

A volume of 0.1 mL bone marrow fluid was extracted from the posterior superior iliac spine (sampling was very difficult), a bone marrow smear was prepared and submitted for examination. Chromosome G-banding karyotype analysis: 3 mL of sterile bone marrow fluid was taken from the patient, and gbanding technique was employed to detect the chromosomes in trypsin-digested short-term cell culture. Karyotype results were analyzed according to the international system for human cytogenetic nomenclature (ISCN, 1991).

We thank the Hematological Tumor Molecular Special Detection Technology Research Center of Kindstar Global (Wuhan) for its technological support.

PML-RARa fusion gene was detected by real-time quantitative PCR: A volume of 2 mL bone marrow fluid with heparin anticoagulant was collected to isolate the mononuclear cells, and total DNA of mononuclear cells was extracted.

Imaging examinations

The following results were revealed: Case 1: 46XY, i(17)(q10)[9]/46, XY[11], long equi arm of chromosome 17; Cases 2: 46XY, Add(14)(P11), i(17)(q10)[4]/46, XY[1], a short arm of chromosome 14 with an additional fragment of unknown origin and a long arm of chromosome 17, as shown in Figure 2.

FINAL DIAGNOSIS

Acute promyelocytic leukemia -like acute myeloid leukemia with i(17)(q10).

TREATMENT

Phase Ⅰ: Two children were treated with ATAR combined with ATO to induce remission: ATAR (30 mg/M2/d), divided 3 times, orally, D1-30; ATO (0.02 mg/Kg), 1 time/day, intravenous infusion, D1-28. Then they were treated with low molecular weight heparin anticoagulant correction therapy based on the coagulation test. Bone marrow cell morphology and leukocyte residual lesions were detected on D29. Blood WBC count was 27.53 × 10/L. Considering the possibility of retinoic acid syndrome, dexamethasone tablets were administered orally at 1.5 mg/time, 3 times a day. With fever regression, WBC was reduced to 12.27 × 10/L on D7. Case 2 showed fever on D2 of treatment, with a temperature of 38.5 ℃, and still had a fever on D3. Blood routine test showed a WBC count of 27.53 × 10/L. Considering the possibility of the retinoic acid syndrome, dexamethasone tablet was taken 1.5 mg/time, 3 times a day. With fever regression, WBC decreased to 12.27 × 10/L in D7.

Phase Ⅱ: On D33, case 1 was treated with the DAE regimen, which including the following: DNR (40 mg/M2/d), D1, 3 and 5, intravenous infusion, once a day; Ara-c (200mg/M2/d), D 1-7, q12h, subcutaneous injection; and Vp-16 /E (100mg/M2/d), D 5, 6, 7, intravenous infusion, once a day. Reexamination of bone marrow cell morphology on D 65 showed no remission. The pediatric patient gave up treatment and discharged themselves. On D154, he came to the hospital again with fatigue, sallow complexion, skin hemorrhagic spots, bone pain, and eyeball herniation. Bone marrow examination showed 85% abnormal promyelocytic granulocytes. D156 Chemotherapy with MAH protocol: M (10 mg/M2/d), D1, 2 and 3; A (200 mg/M2/d), D1-7, q12h, subcutaneous injection; and H (3 mg/M2/d),D 1-7, subcutaneous injection. Case 2 was treated with the MAH regimen on D 47 and D80. The doses and methods were as above. On D115, he was treated with IDA (10mg/M2/ D1-3); intravenous infusion; once a day. The dosage and usage of the ara-C and H were the same as before. On D145, bone marrow cell morphology was evaluated, residual lesions were detected by flow cytometry, and WT1 gene copy number was detected by molecular biological techniques (See Methods). On D175, he was treated with HD ara-C (2.0 g/M2/d); D1, 3, 5 and 7; q12h. The dose and usage of HD ara-C were the same as above. On D205, HD ara-C dose and usage were the same as above: Vp-16 (100 mg/M2/d), D1-5; intravenous infusion. On D 235, he received HD ara-C (3.0g/M2/d); D1, 3, 5, 7; q12h; the dose and usage were the same as above. During D265-730, 6-MP [50 mg/M2/d (D1-21)] plus low-dose ara-C (40mg/M2) were given. D1-4 (D22-28) maintenance therapy: Bone marrow cell morphology was returned one year after drug discontinuation, residual lesions were detected using flow cytometry, and WT1 gene copy number was detected by molecular biological tools (See methods).

OUTCOME AND FOLLOW-UP

There is no history of past illness.

Karyotype analysis

There is no imaging examinations.

Fully-instrumented submersible housing detection

Case 1: The nuclear in situ hybridization (nuc ish) (PML × 2, RARA × 3) (180/400) showed no fusion signal by PML/RARA translocation probe, and the copy number of RARA (located at 17q21) site increased, accounting for about 45%.

Case 2: The nuc ish (PML × 2, RARA × 2) showed no abnormal signal in the PML/RARA locus, and the detection result was negative as shown in Figure 3.

Immune typing

Abnormal cells were accounted for 88% in Case 1 and 78% in Case 2. Flow cytometric analysis on CD45/SSC dot plot showed that CD9, CD13, CD33, and CD38 were mainly expressed in all analyses, while CD64, CD123, and MPO were only expressed in some analyses. CD58 was expressed in case 1 and CD15 was expressed in case 2, as shown in Figure 4. Molecular biological detection: PML/RARa, PLZF/RARa, NPM/RARa, STAT5b/RARa, NuMA1/RARa, PRKARIA/RARa, and FIPIL1/RARa fusion-gene tests showed negative results.

Detection of gene (exon) variation related to myeloid and gonorrhea hematologic malignancies was performed by targeted capture method. Mutation sites were clearly associated with the disease, and all of them had mutations of WT1 (Wilms Tumor 11). Case 1 WT1: NM_024426: exon9:c.G1367C:p.C456s; mutation frequency 49.2%. Case 2 WT1: NM_024426:exon1:c.410_413del:p.137_138del; mutation frequency 100%. Case 1 with EP300 (E1A Binding Protein p300) mutations: NM_001429: exon31:c.C5449T:p.Q1817X; mutation frequency 72.1%.

在經歷了這樣特殊的課程之后，從新加坡中學走出來的學生具有非常敏銳的“批判性思維”和“辯證思維”，他們的邏輯思維能力快速成長，也同樣對于他們的學術課程大有助益。

For case 1, the following mutation sites might be associated with the disease: (1) USP6 (NM_004505:exon12:c.854delG:p.W285fs) was a frameshift mutation, with a mutation frequency of 32.6%; (2) NUTM2G (NM_001170741:exon7:c.C2102T:p.701L) was a missense mutation, with a mutation frequency of 78.8%.

He was diagnosed with APL 3 years ago in a local hospital based on bone marrow morphology and immunological classification, with negative PML-RARa fusion gene at the time of diagnosis.The patient received all-trans retinoic acid (ARAT) and arsenic trioxide (ATO) as induction therapy, and bone marrow examination showed no tumor remission on D29. He then received three cycles of consolidation therapy (DA, HA, and MA regimen) and maintenance therapy, bone marrow evaluation showed complete remission, and the treatment was stopped.

綜上所述，隨著信息時代的到來，為了跟上網絡發展的步伐，我們應該提高新聞編輯的價值，根據實際情況強化信息的使用質量，這對于新聞發展有著比較大的作用。而新聞播音主持作為公眾人物，應該注意從自身做起，提高自身的語言表達能力，時刻記著自身的責任和義務，在播報的過程中將自身的個性化技巧表現出來，吸引人們的注意力，從而在一定程度上提高電視新聞的收視率，促進電視新聞播音主持行業的發展。

由于風力發電機組多安裝在高山、荒野、海島等風口處，受無規律的變向變載荷的風力作用以及強陣風的沖擊，加之所處的自然環境交通不便，而且機組安裝在塔頂的狹小空間內，一旦出現故障，修復非常困難，故對其可靠性等提出了比一般機械高得多的要求。大量的實踐證明，整個機組的薄弱環節常常就是齒輪箱。因此，風力發電機組齒輪箱在投入使用前，都會進行嚴格的試驗，以確保其高可靠性。而測試齒輪箱的變頻電動機，必須經受齒輪箱的各種復雜工況，這也就對電動機提出了較高的要求。

Treatment outcome

Case 1 review of bone marrow on D29 and D65: It was still very difficult to collect bone marrow; myelodysplastic hyperplasia was pronounced; abnormal promyelocytic granulocytes were 33% and 78%, respectively; the treatment was ineffective on D156; MAH regimen was used for chemotherapy; the patient died of intracranial hemorrhage on D162.

1.2.5 評價標準 ①對糖尿病知識的認知≥60為合格。②綜合干預的效果評價包括飲食控制、運動和血糖、尿糖監測。

在開展高中政治課程的教學過程中，教師既能夠將微課運用在實際的課堂教學過程中，同時也能夠使政治課堂向外拓展，在平時的生活中給予學生適當的輔助與指導，讓其可以學習到比較全面的政治教育知識，將政治教育的作用與目的充分發揮出來。概括來講，教師應該相應地制作一些與高中政治課程教學重難點內容相關的課件，引導學生在課下進行深入學習，尤其是就部分在課堂上未能切實掌握此部分內容的學生而言，如果在課下得到教師正確的教學指導，就可以系統性地了解相關知識內容，從而不僅能夠進一步提高學習效率，而且還能對他們的學習能力與學習興趣進行培養。

Case 2 review of bone marrow on D29: It was still very difficult to obtain bone marrow samples; myelodysplasia decreased and promyelocytic granulocytes accounted for 32%. On repeated examination of bone marrow on D46, D145, D265 to D730, it was still very difficult to obtain bone marrow samples; reduced myelodysplasia was observed; abnormal morphology of promyelocytic granulocytes accounted for 2%; cytoplasm contained a large number of arrocysts; nuclei had lumps and no nucleolus. Residual leukemia detection revealed no immunophenotypic abnormal cell population (residual leukemia cells < 10); complete remission occurred. Up to now, the drug has been discontinued for 1 year, and the clinical, morphological, and flow cytometry results continued to show complete remission. However, the copy number of thegene was 1010-1087, and the expression rate was 51.95%-55.29%, which indicated the risk of recurrence, and allogeneic hematopoietic stem cell transplantation was necessary.

DISCUSSION

APL is a rare subtype of AML and has different morphological and immunological characteristics compared with other myeloid leukemia cells. Karyotype t (15;17) is a unique chromosome translocation in APL. At the molecular level, PML/RARα fusion gene is formed by translocation of PML gene at 15q and RARα gene at 17q.Therefore, it is a highly specific cytogenetic marker for this type of leukemia. In this case study, the phenotype of 2 children showed typical APL characteristics, especially some cells had inner and outer plasma membrane, with thick azinophilus granules (Figure 1). Immunophenotypic markers mainly included CD9, CD13, CD33, CD38 (Figure 2), and CD64, CD123, MPO were also expressed in case 1. In addition, case 1 also had the expression of CD15, which was consistent with the immunophenotype of APL[16,17] and the isolated i(17)(q10) AML with similar APL morphology.

Previously, 4 isolated i(17) (q10) cases were reported, including 2 children[13,14], 1 adult[15], 1 case without age information[18], and 3 cases with M3 (APL) FAB classification. There were no t(15;17) and PML-RARa fusion gene detected and patients had no responses to ATRA treatment[15]. One case did not respond to chemotherapy and the survival time was less than 1 mo[14]. The other 2 cases did not mention prognosis[13,19]. In this study, there were 2 cases examined, case 1 was isolated i(17)(q10), case 2 was isolated i(17)(q10) add(14)(p11). The t(15;17) was not present, and PML-RARa fusion gene was not detected by Fully-instrumented submersible housing and second-generation sequencing, which rendered ATRA and AsOcombined chemotherapy ineffective. Case 1 survived 5.5 mo. Case 2 achieved sustained complete remission after intensive chemotherapy with acute non-eluting regimen. The difference might not be related to isolated i(17)(q10) add(14)(P11), which was speculated to contribute to the transport of chemotherapeutic drugs. Similar studies have not been reported on leukemia patients, and the underlying specific mechanism needs further exploration. However, with the high expression ofgene, the risk of recurrence is still very high[20]. Further clinical follow-up is required, and hematopoietic stem cell transplantation is necessary. However, this case was different from occult APL and APL with i(17)(q10) and PML-RARa fusion gene, for which the ATRA and AsOcombined chemotherapy was effective[2,18].

Patients with myeloid tumor i(17)(q10) are mostly MDS/MPO+ patients with a chronic history, and often have pathological hematopoiesis in granulocyte, erythrocyte, and megakaryocyte lines, with an average of 3 gene mutations, mainly,, and[8,9]. In this study, 2 patients had a short course of the disease, with no history of MDS/MPO+, and no erythrocyte or megakaryocyte pathological hematopoiesis except granulocyte lineage, which was similar to a 27-year-old female APLlike AML patient with a short course of the disease, having no chronic history and multi-family pathological hematopoiesis[15].

Gene mutations in these APL-like AML cases were reported for the first time, and there were 5 mutations in case 1, including WT EP300 c.854delg: P w285fs frame-shift mutation and C.C2102T: P 701L missense mutation.,,, andmutations were found in case 2. Both cases hadgene mutations, which were consistent with the characteristics of i(17)(q10) gene mutations (0-6) in MDS/MPO+ patients, but the gene mutation points were completely different. Therefore, case with i(17)(q10) was clinically diagnosed. The morphological diversity was probably due to different mutation patterns, and the number and order of the mutations might play a key role[8]. Therefore, both morphologic and immunological manifestations of APL were found in 2 children without t(15;17) and PML-RARa fusion-gene expression. Though preliminary diagnosis of AML morphologically similar to APL[15] were made for both children, the treatment failed in case 1, and case 2 with add(14)(p11) achieved sustained complete remission after chemotherapy, which might be related to the different gene mutation points.

Through literature review, 6 patients with i(17)(q10) have been known (including 2 in this group), 5 morphologically similar to AML, 1 without FAB classification mentioned[13], 5 with isolated TYPE i(17)(q10), 1 with add(14)(p11), and 3 patients (including 2 in this group) had CD33 immunophenotype with CD3 MPO expression[15]. Using existing genetic and molecular biological techniques, t(15;17) among the 6 patients with PML-RARa fusion gene were not detected, 3 patients failed to respond toATRA-AsOand chemotherapy and died (survival shorter than 5.5 mo), 1 patient achieved sustained complete response after chemotherapy, and 2 patients did not show prognosis[13,18].

著作權法采取“以用設權”的方式意味著，如果法律賦予作者控制某種作品使用行為，那么第三人實施這一行為時，需獲得權利人的授權許可。換言之，權利人控制作品使用行為，也就有權從第三人使用作品的行為中獲益。然而，作品使用行為是難以完全列舉的，對于一些作品使用行為未被法律定性化為有名權利，而立法又未明確否定的利益，該如何保護？對此，各國有不同的做法。

Morphology, immunology, chromosomal karyotype, and molecular biological genotyping of 6 cases with i(17)(q10) in different periods and their prognosis are shown in Table 1.

CONCLUSION

APL-like AML with i(17)(q10) has morphological and immunological characteristics similar to APL, without t(15;17) and PML-RARa fusion gene expression. ATRA-AsOand chemotherapy were not effective in treating the patients, with short survival period. If a chromosomal addition occurred, a sustained complete remission should be achieved and related clinical manifestations should be revealed. It is necessary to further strengthen the molecular biological study and collect a large number of cases to provide better treatment strategies.

ACKNOWLEDGEMENTS

Immunophenotype: 2 mL of bone marrow fluid with heparin anticoagulant was obtained, 5x10-5×10/mL cells were isolated using FACSort flow cytometry (BD Biosciences) and analyzed with CellQuest software > The expression levels of leukemia related antigens in the cell population were analyzed and calculated. Monoclonal antibodies used included HLA-DR, CD2, CD3, CD4, CD7, CD8, CD9, CD11b, CD13, CD14, CD15, CD16, CD19, CD22, CD33, and CD34 Labeled by FITC, PE, and PerCP, or APC- CD38, CD56, CD64, CD71, CD117, CD123, and MPO. All antibodies were purchased from BD Biosciences.

（3）施工重點環節不精準。如驗收開鉆、定點測斜，進入沙河街等特殊地層、水平井使用地質導向儀器、電測、下套管、固井等特殊環節，井隊一直以原有的施工方式方法實施，缺乏精準性。

FOOTNOTES

Yan HX and Wen JQ contributed to conception and design of the study; Yan HX and Zhang WH are the co-first author; Zhang WH organized the database; Yan HX wrote the first draft of the manuscript; all authors contributed to manuscript revision, read, and approved the submitted version.

Shaanxi Natural Science Foundation, No. 2020SF-004.

Consent was obtained from relatives of the patient for publication of this report and any accompanying images.

The authors declare that they have no conflicts of interest.

為酒店客人提供的入住引導服務是通過在酒店里面布置引導牌來實現的。根據客人所持的標識卡，并經過樓底系統、PMS系統、電子牌控制系統、感知系統等對客人進行一步步的引導，讓客人可以在結構復雜的酒店中迅速、方便地找到自己的房間。所有入住酒店的客人都可以享受到入住引導服務。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Hong-Xia Yan 0000-0002-1722-716X; Wei-Hua Zhang 0000-0002-4579-3492; Jin-Quan Wen 0000-0001-9202-6598; Yan-He Liu 0000-0001-5141-8122; Bao-Juan Zhang 0000-0002-1534-9622; A-Duo Ji 0000-0001-6328-6227.

Xing YX

A

但是，通過研究英語和漢語中人體詞的多義性，我們也發現英、漢兩種語言在人體詞的語義轉移方面有不少異同點。我們會不斷研究，將情感、文化等因素考慮在內，以期發現兩種語言人體詞意義構建上的差異性。

Xing YX