
==== Front
Leuk Res Rep
Leuk Res Rep
Leukemia Research Reports
2213-0489
Elsevier

S2213-0489(24)00068-2
10.1016/j.lrr.2024.100478
100478
Article
Acute myeloid leukemia with a ZMYND11::MBTD1 fusion gene following chemotherapy and radiotherapy for breast cancer: A case report
Kawai Hidetsugu ab
Shiraiwa Sawako a
Ogiya Daisuke a
Toyosaki Masako a
Machida Shinichiro a
Suzuki Rikio a
Onizuka Makoto a
Ogawa Yoshiaki a
Kawada Hiroshi kawada@tokai.ac.jp
a⁎
a Department of Hematology / Oncology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
b Department of Hematology, Hiratsuka Mutual Aid Hospital, Hiratsuka, Kanagawa, Japan
⁎ Corresponding author: Hiroshi Kawada, Department of Hematology /Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan. kawada@tokai.ac.jp
21 8 2024
2024
21 8 2024
22 10047815 6 2024
25 7 2024
19 8 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The t(10;17)(p15;q21) translocation is a very rare recurrent cytogenetic aberration, and produced ZMYND11::MBTD1 fusion gene. To date, nine cases of acute leukemia with the t(10;17)(p15;q21) translocation have been reported, but the case of AML with ZMYND11::MBTD1 after chemotherapy and radiotherapy have not been reported. Epirubicin-based chemotherapy or radiotherapy for breast cancer increases the risk of developing secondary leukemia. We report a case of AML with the ZMYND11::MBTD1 fusion gene that developed after epirubicin-based chemotherapy and radiotherapy for breast cancer. previous chemotherapy and radiotherapy may be associated with poor prognosis of AML with ZMYND11/MBTD1.

Keywords

ZMYND11-MBTD1 fusion gene
Leukemia after chemotherapy and radiotherapy in patients of breast cancer
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pmc1 Introduction

The t(10;17)(p15;q21) translocation is a very rare recurrent cytogenetic aberration, and 10 cases of acute leukemia with t(10;17)(p15;q21) translocation have been reported to date [1] [2],. These 10 cases were classified as 5 cases of acute myeloid leukemia (AML) M0, 4 cases of AML M1, and 1 case of B-cell lymphoblastic leukemia (B-ALL) according to the French-American-British (FAB) criteria. In these cases, a fluorescence in situ hybridization (FISH) analysis revealed that the ZMYND11 (zinc finger MYND-type containing 11, alias BS69) gene on 10p15.3, and the MBTD1 (mbt domain containing 1) gene on 17q21.33, colocalized in 2 cases [3,4]. In addition, a sequencing analysis identified an in-frame fusion of ZMYND11 exon 11 or exon 12 with MBTD1 exon3 in the other 3 cases [1,5]. AML with ZMYND11::MBTD1 is characterized by positivity for CD13, CD33, CD7 and CD56, and the activation of pro-leukemia genes including Hoxa, Meis1, Myb, Myc and Sox4 [6].

Secondary AML may be associated with chemotherapeutic drugs and/or radiation therapy for various primary tumors. Anthracycline-based chemotherapy has significantly improved breast cancer outcomes. The long-term toxicity, such as secondary leukemia or cardiotoxicity, results in worsening the quality of life or the prognosis. In addition, combined with alkylating agents or radiotherapy increases the risk of developing secondary leukemia. Several studies have reported the incidence rate of secondary leukemias after epirubicin-based adjuvant chemotherapy. Campone. M, et al. reported that the risk of developing leukemia was about 0.3 % in epirubicin-exposed patients with breast cancer, and various types of secondary leukemias after epirubicin-based chemotherapy [7].

To date, AML cases with ZMYND11::MBTD1 after chemotherapy and radiotherapy have not been reported. Here, we report a case of AML with the ZMYND11::MBTD1 fusion gene that developed after chemotherapy and radiotherapy for breast cancer.

2 Case presentation

The patient was a 67-year-old woman who has been diagnosed with breast cancer 2 years ago. The patient was treated with epirubicin, cyclophosphamide, trastuzumab, pertuzumab, radiotherapy, and hormone therapy as preoperative and postoperative chemotherapies. The hemoglobin level, platelet count, and leukocyte count were normal, and cytopenia disappeared. She complained of a low fever. The patient did not have palpable hepatosplenomegaly or lymphadenopathy. A laboratory test revealed the following findings: hemoglobin, 5.1 g/dL; platelet count, 2.1 × 109/L; leukocyte count, 3.6 × 109/L including 10.0% blasts; prothrombin time (PT), 13.2 s; activated partial thromboplastin time (APTT), 26.2 s; FDP, 11.6 µg/mL; d-dimer, 5.5 µg/mL; fibrinogen 635.3 mg/dL; lactase dehydrogenase, 2952 U/L (high). Bone marrow examination revealed that 76.3 % of peroxidase-negative blasts had fine nuclear bodies. Some blasts had multiple nuclei or blebs (Fig. 1-A). Flow cytometric analysis revealed positivity for CD13, CD33, CD34, CD117, CD7, and CD56, and negativity for MPO, CD41, CD42b, CD61, other B-cell markers, and T-cell markers among the blasts (Fig. 1-B). Chromosomal analysis of the bone marrow cells revealed 46, XX, t(10;17)(p15;q21.3) [17] / 46, XX [3] (Fig. 1-C). Fish analysis revealed that the blasts were negative for KMT2A rearrangement. The patient did not have extramedullary involvement. According to WHO 2022, the patient was diagnosed with AML with other defined genetic alterations.Fig. 1 Bone marrow sample and detection of the ZMYND11-MBTD1 fusion gene.(A) Images of blasts obtained by the bone marrow sample at the time of the diagnosis. Medium- to large-sized blasts showed fine nuclear chromatin, multiple nuclei, and no azurophilic granules. (B) Flow cytometry of bone marrow cells by CD45 gating at the time of the diagnosis. Gated cells were positive for CD13, CD33, CD34, CD7, and CD56. (C) G-band analysis of bone marrow cells at the time of the diagnosis. Arrows indicate rearranged chromosomes. (D) PCR products of samples at the time of relapse. The left lane is a size marker and the right lane represents GAPDH as a control. Each primer was indicated as follows, F1: Forward 1, F2: Forward 2, F3: Forward 3, F4: Forward 4, R1: Reverse 1, R2: Reverse 2.(E) Sequencing analysis. The breakpoint is indicated by an arrow. ZMYND11 exon 12 fused to MBTD1 exon 3 in the frame.

Fig 1

Complete remission (CR) was achieved with induction therapy (idarubicin and cytarabine). CR was sustained with consolidation therapy (three courses of high-dose cytarabine). However, six months after the final chemotherapy, the patient experienced relapse in the bone marrow and central nervous system (CNS). At the time of relapse, the karyotype was the same as that at the initial diagnosis. The best supportive care was provided, and the patient died 10 months after diagnosis.

We performed reverse transcription-polymerase chain reaction (RT-PCR) using cDNA extracted from a bone marrow sample at the time of relapse. Four forward primers (F1,F2,F3, and F4) for ZMYND11 and two reverse primers (R1 and R2) for MBTD1 were designed (Table 1). PCR was performed using a combination of forward and reverse primers, and specific bands were detected in each lane (Fig. 1-D). Because the F3 primer covered the breakpoints of ZMYND11-MBTD1, it was not possible to detect the PCR product. Nucleotide sequencing analyses of the PCR product detected in combination with F2-R1 primers revealed a ZMYND11-MBTD1 fusion gene, in which ZMYND11 exon 12 was fused to MBTD1 exon 3 in frame (Fig. 1-E).Table 1 Primers for PCR.

Table 1Name	Gene / Location	Sequence	
Forward 1	ZYMND11 / exon 8	5′-TTGCGAGGATGCTATATAAAG-3′	
Forward 2	ZYMND11 / exon 10	5′-GGCCAGCCAAAGTCAT-3′	
Forward 3	ZYMND11 / exon 12–13	5′-GAGCCCAAAAAGGAAGAA-3′	
Forward 4	ZYMND11 / exon 12	5′-GAGGACCGAGGTGAGGAAGA-3′	
Reverse 1	MBTD1 / exon 3–1	5′-TGCCCATTGTTTTTGATAA-3′	
Reverse 2	MBTD1 / exon 3–2	5′-TCACTCTCTTCGGAGCTGGA-3′	

3 Discussion

Here, we report a rare case of AML with t (10;17)(p15;q21.3) that developed after chemotherapy and radiotherapy for breast cancer. Nucleotide sequencing analyses revealed ZMYND11-MBTD1 fusion gene with ZMYND11 exon 12 was fused to MBTD1 exon 3 in frame.

With regards to t(10;17)(p15;q21) translocation, Yamamoto et al. reported nine cases of AML with t(10;17)(p15;q21) translocation [1]. In addition, Plesa et al. reported 1 such case [2]. The ZMYND11::MBTD1 fusion gene was confirmed in 5 AML cases. Three AML M0 cases presented immunophenotypes similar to those of Myeloid/NK precursor cell acute leukemia (MNKPL): blasts were commonly positive for CD13, CD33, CD34, CD7 and CD56, and negative for MPO. Two AML M1 cases presented immunophenotypes similar to that of myeloid/NK cell acute leukemia (MNKL): blasts were commonly positive for CD13, CD33, CD7, CD56, MPO, and negative for CD34 [1]. Based on these characteristics, the cell surface antigen expression pattern of blasts previously reported as AML with ZMYND11::MBTD1 was the same as that of MNKPL or MNKL. ZMYND11 exon 11 or exon 12 was fused to MBTD1 exon 3 in frame, and no significant differences were observed between the ZMYND11 exon 11 and the exon 12 types. The patient was treated with epirubicin for breast cancer. Among the 2603 patients who received adjuvant epirubicin-based chemotherapy, 8 cases (0.31 %) had secondary leukemia. These 8 cases included various FAB subtypes, chromosomal abnormalities, and prognoses [7].

MNKPL has been advocated by Suzuki et al., and is commonly reported in the Asian population, although this entity is not universally recognized and is not categorized by the WHO classification. Flow cytometric analysis revealed that blasts were positive for CD7, CD34, CD56, and myeloid markers (CD13 and CD33) but negative for myeloperoxidase (MPO) and other lymphoid markers [8]. MNKPL is different from myeloid/NK cell acute leukemia (MNKL), that is characterized by MPO expression and the presence of azurophilic granules. The immunophenotype of MNKL is positive for CD13, CD33 and CD56, and negative for CD34 [9,10]. Patients with MNKPL frequently exhibit extramedullary disease with lymphadenopathy and/or bulky mediastinal masses, and their prognosis is poor [8,11]. MNKPL is characterized by the activation of the NOTCH1 pathway with the downregulation of BCL11B and the RUNX3 overexpression [12]. Clinically, extramedullary involvement was not detected in any of the 10 cases with t(10;17)(p15;q21) translocation, and their prognoses were not always poor. The clinical characteristics of AML with t(10;17)(p15;q21) translocation were different from those of MNKPL. The current case also showed the same immunophenotypic pattern as that of MNKPL, however the patient did not have extramedullary involvement. The prognosis of this case was the second poorest of all acute leukemias with t(10;17)(p15;q21) translocation.

ZMYND11 is a candidate tumor suppressor. ZMYND11 recognizes tri-methylated histone H3.3 lysine-36 (H3.3K36me3) and suppresses the phenotypes of cancer cells via H3.3K36me3-binding activity [13]. The N-terminal domains of ZMYND11 (PHD, bromo, and PWWP (Pro-Trp-Trp-Pro)) showed chromatin association activity. The bromo and PWWP domains retained in ZMYND11/MBTD1 recognize the function of H3.3K36me3 [13]. In contrast, MBTD1 belongs to the polycomb group of proteins, and functions as a transcriptional repressor of genes that affect tumor suppression [14]. MBTD1 consists of a TCS-type zinc finger (ZnF) at the N-terminus and four malignant brain tumor (MBT) repeats at the C-terminus. These domains are retained in ZMYND11/MBTD1, and the fourth MBT domain binds to mono- and di-methylated histone H4 lysine-20 (H4K20me1/2) [13]. MBTD1 has been identified as a subunit of the NuA4/TIP60 acetyltransferase complex, that has histone acetylation activity. ZMYND11/MBTD1 demonstrates the essential requirements for oncogenesis: TIP60 interaction and H3K36me3-binding PWWP domain. Methylation and acetylation contribute to the high expression of pro-oncogenic targets such as Hoxa9, Meis, Sox4, Myc and Myb. Brd4 acts downstream of the ZMYND11/MBTD1:TIP60 complex and is a druggable gene [6]. A selective Brd4 inhibitor treatment blocked cell proliferation and increased cell death in vitro and in vivo, and is expected to be a new treatment for patients with acute leukemia with ZMYND11/MBTD1 [6]. In contrast, it has been reported that AML-type chemotherapy combined with L-asparaginase provides better overall survival than other types of chemotherapy in children, adolescents, and young adults with MNKPL [12]. These results indicate that the appropriate treatment strategy for AML with ZMYND11/MBTD1 may differ from that for MNKPL.

AML with ZMYND11/MBTD1 may have the same immunophenotypic patterns as MNKPL or MNKL, with blasts commonly positive for CD13, CD33, CD7, and CD56. However, AML with ZMYND11/MBTD1 can be distinguished from MNKPL in terms of the presence or absence of extramedullary involvement and gene expression, and should be managed with a different therapeutic approach. Previous chemotherapy and radiotherapy may be associated with poor prognosis of AML with ZMYND11/MBTD1.

Informed consent

The patient's frozen bone marrow samples were obtained after written informed consent was provided in accordance with the Declaration of Helsinki and with approval from the Tokai University Committee on Clinical Investigation (Permit number: #15I-26).

CRediT authorship contribution statement

Hidetsugu Kawai: Writing – original draft, Funding acquisition, Formal analysis, Data curation, Conceptualization. Sawako Shiraiwa: Data curation. Daisuke Ogiya: Data curation. Masako Toyosaki: Data curation. Shinichiro Machida: Data curation. Rikio Suzuki: Writing – review & editing, Data curation. Makoto Onizuka: Writing – review & editing, Data curation. Yoshiaki Ogawa: Data curation. Hiroshi Kawada: Writing – review & editing, Funding acquisition, Data curation.

Declaration of competing interest

The authors declare no conflicts of interest in association with the present study.

Acknowledgments

We thank Mr. Hideyuki Matsuzawa, and Ms. Keiko Yokoyama (Medical Science College Office, Tokai University) for technical assistance. This work was supported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan (H.K.).
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