We prospectively observed a child exposed to intensive multimodality therapy for metastatic neuroblastoma from emergence of a MLL translocation to disease diagnosis. The t(4;11)(p12;q23) was detected in the marrow 17 months after starting treatment following topoisomerase II poisons, alkylating agents, local radiation, hematopoietic stem cell transplantation, anti-GD2 monoclonal antibody with granulocyte macrophagecolony-stimulating factor, and a high cumulative dose of oral etoposide. Reciprocal genomic breakpoint junctions and fusion transcripts joined MLL with FRYL, the Drosophila melanogaster protein homologue of which regulates cell fate. Etoposide metabolites induced topoisomerase II cleavage complexes that could form both breakpoint junctions. Cells harboring the translocation replaced the marrow without clinical evidence of leukemia and differentiation appeared unaffected for 37 months. Subsequent bilineage dysplasia and increased blasts in addition to the translocation fulfilled criteria for MDS. The
IntroductionEpipodophyllotoxins, anthracyclines, and other chemotherapeutic topoisomerase II poisons are associated with leukemias with translocations of the MLL gene at chromosome band 11q23. The MLL gene product is a multidomain oncoprotein that functions in a macromolecular protein complex to regulate transcription. [1][2][3] Recently dubbed the "MLL recombinome," the approximately 50 MLL partner genes encode diverse nuclear transcription factors, transcriptional regulatory proteins, and cytoplasmic or cell membrane proteins. 4 Murine experiments have converged upon a model where heterogeneous MLL fusion oncoproteins affect the incidence or phenotype of leukemia by altering Hox expression. 5,6 It has been proposed that MLL translocations fall into a group of mutations that impair differentiation 7 and that cooperating mutations that confer a proliferative and/or survival advantage to hematopoietic progenitors (eg, mutation or overexpression of FLT3 [8][9][10] ) are required for leukemia to occur.Many MLL fusion proteins from the der(11) chromosome immortalize murine hematopoietic progenitor cells in serial replating assays and/or cause leukemia in mice. [11][12][13][14][15][16][17] However, certain MLL translocations with genes encoding some of the cytoplasmic partner proteins (eg, GRAF, FBP17, ABI1, LASP1) are inactive in serial replating assays, which may reflect the requirement for cooperating alterations. 18,19 Although nearly all known MLL translocations, including those inactive in serial replating assays, [18][19][20][21] manifest as leukemia/myelodysplastic syndrome (MDS) in patients; in one patient, the morphologically normal clone harboring an MLL-ARHGEF17 translocation steadily declined over 30 months, and neither leukemia nor MDS occurred. 22 We characterized a chemotherapy-associated MLL translocation with the partner gene FRYL (furry homolog-like; originally called MIFL [MLL Insufficient for Leukemia]), and prospectively followed the clinical course of the affected patient. First MLL-FRYL ...