|Year : 2019 | Volume
| Issue : 1 | Page : 1-5
Flow cytometric assessment of CD30 expression in adult patients with acute leukemia
Amal M Elafifi1, Rasha M Said MD 1, Haitham M AbdElbary1, Rasha Abdulrahman2, Kouthar Ali3
1 Hematology Department and BMT Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
3 Hematology Department, Sabratha Oncology Center, Libya, Egypt
|Date of Submission||20-Jan-2019|
|Date of Acceptance||30-Jan-2019|
|Date of Web Publication||27-Sep-2019|
Dr. Rasha M Said
Lecturer of Hematology and Bone Marrow Transplantation Unit, Faculty of Medicine, Ain Shams University, 74/1 El Saudia Buildings, Street 306, New Maadi, Cairo
Source of Support: None, Conflict of Interest: None
Background CD30, a member of tumor necrosis factor receptor superfamily, was originally identified as a cell-surface marker of Reed–Sternberg cell in classical Hodgkin lymphoma. CD30 is also expressed by several types of T-cell and B-cell non-Hodgkin’s lymphoma, such as anaplastic large cell lymphoma and primary mediastinal large B-cell lymphoma, and Epstein–Barr virus driven clonal lymphoproliferative disorder, as well as in reactive conditions such as infectious mononucleosis.
Patients and methods A cross-sectional study was conducted at Clinical Hematology Department in Ain Shams University Hospital during a period from November 2016 to August 2017. A total of 20 new cases of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) and 30 refractory/relapsed cases of AML and ALL either T or B, were enrolled in this study. CD30% expression was assessed by flow cytometry on bone marrow sample or peripheral blood.
Results CD30 with cutoff more than 20% (+ve) was seen in 46% of cases, whereas cases with cutoff less than 20% (−ve) represented 54% of all leukemia cases. CD30 expression was higher in ALL, especially in T–acute lymphocyctic leukemia (T-ALL), with mean value of 44.564±27.158, with significant increase relapsed T-ALL (P=0.031) followed by B-ALL (23.988±15.678). CD30 expression in relapsed AML and ALL showed an increased percent but not yet statistically significant. Significant correlation was found in risk parameters as in white blood cells (WBCs) (>100 000) as well as Platlets (PLT) (<30 000) and CD30 expression in patients with T-ALL, with P values of 0.038 and 0.021, respectively, and nonsignificant difference between lactate dehydrogenase (LDH) and minimal residual disease in T-ALL and all risk parameters in B-ALL. Receiver operator characteristic (ROC) curve revealed that the accuracy of sensitivity and specificity was 69.9%.
Conclusion CD30 has been shown to be a significant diagnostic tool in cases of acute leukemia especially in newly and relapsed T-ALL; moreover, it can be labeled to be a targeted therapy. Drug trials using monoclonal antibodies to CD30 as treatment in relapsed/refractory cases with special concern to response and survival rate are needed.
Keywords: anaplastic large cell lymphoma, Epstein–barr virus, minimal residual disease, primary mediastinal large B-cell lymphoma, tumor necrosis factor receptor
|How to cite this article:|
Elafifi AM, Said RM, AbdElbary HM, Abdulrahman R, Ali K. Flow cytometric assessment of CD30 expression in adult patients with acute leukemia. Egypt J Haematol 2019;44:1-5
|How to cite this URL:|
Elafifi AM, Said RM, AbdElbary HM, Abdulrahman R, Ali K. Flow cytometric assessment of CD30 expression in adult patients with acute leukemia. Egypt J Haematol [serial online] 2019 [cited 2019 Oct 23];44:1-5. Available from: http://www.ehj.eg.net/text.asp?2019/44/1/1/268005
| Introduction|| |
Acute myeloid leukemia (AML) is an aggressive neoplasm with maturation arrest of myelopoiesis, leading to an accumulation of myeloblasts in bone marrow and/or blood ,.
FLT3 tyrosine kinase is expressed in ∼30% of AML, the C-KIT tyrosine kinase is expressed in 60–80% of patients with AML, and receptor tyrosine kinase mutation has been documented in ∼50% of cases of AML . In acute prolymphocyctic leukemia (APL), retinoic acid plays a key role in myeloid progenitor differentiation through its nuclear receptors and retinoid X receptors .
For younger adult patients, de-novo AML remains a challenge. Although more than 70% of such patients will enter a first complete remission (CR1) after induction chemotherapy, a substantial number of patients experience disease relapse. Allogeneic hemopoietic stem cell transplantation after myeloablative conditioning is a curative treatment option for younger patients with AML in CR1 .
Acute lymphoblastic leukemia (ALL) remains first of the most challenging adult malignancies, especially with respect to therapy. Immunophenotyping, cytogenetic-molecular studies, and more recently, high-resolution genome-wide study characterize ALL as a heterogeneous disease with distinct manifestations and prognostic and therapeutic implications .
The presence of the Philadelphia chromosome has defined ALL with an unfavorable prognosis. The advent of tyrosine kinase inhibitors profoundly changed the management and prognosis of these high-risk patients . Common features of BCR-ABL1-like ALL include translocations involving other tyrosine kinases, or alternatively translocations involving either the cytokine receptor-like factor 2 or less commonly, rearrangements leading to activation of the erythropoietin receptor. Cases with cytokine receptor-like factor 2 translocations are often associated with JAK gene mutations .
There is a close positive association between rapid minimal residual disease (MRD) reduction and the duration of CR. Monitoring MRD helps guide the decision to use stem cell transplant or maintenance treatment .
CD30 is a 120-kDa cell membrane glycoprotein. Its gene locus is on chromosome 1p36. The receptor is expressed on activated B and T cells, and intercedes in signal transductions involving nuclear factor-β transcription. The human CD30 comprises 595 amino acid residues. The extracellular and cytoplasmic domains of human CD30 consist of 362 and 188 residues, respectively. CD30 has a molecular mass of 85–90 kDa .
High serum levels of soluble sCD30 have prognostic significance for patients with CD30-positive lymphomas and viral infections. Activation of CD30 by ligand binding or cross-linking with immobilized antibody leads to trimerization of the receptor, recruitment of signaling proteins, and transduction of numerous effects.
Many different outcomes of CD30 stimulation have been reported, including cell cycle arrest, apoptosis, and activation of the prosurvival transcription factor nuclear factor-β .
CD30 has emerged as an important molecule in the field of targeted therapy, because its expression is generally restricted to specific disease types and states .
| Aim|| |
The aim of the work is to assess CD30 in patients with newly diagnosed acute leukemia myeloid and lymphoid, either B or T type, and also the relapsed and refractory type for the efficacy of anti-CD30 therapy.
| Patients and methods|| |
This study was carried out on 10 new cases of patients with AML and 10 new cases of ALL, 15 refractory/relapsed cases of AML, and 15 refractory/relapsed cases of ALL, either T-cell or B-cell type. The number of male patients with AML was 14 of 25 (56%) whereas the female patients with AML were 11 (44%) of 25 patients. On the contrary, the number of male patients with ALL was 14 (56%) of 25, whereas the female patients with ALL were 11 of 25 (44%).
The number AML cases in M0 was three of 25, in M1–M2 was 20 out of 25, in M3 and M4 was only one case of 25 cases. Regarding ALL, pre-B-ALL was 11 out of 25, B-ALL was three out of 25, pro-T-ALL was one case, T-ALL was five out of 25, and pre-T-ALL was five case of 25 cases.
All patients were recruited from Hematology Unit at Ain Shams University Hospital after informed consent.
Patients and methods
BM aspirate or peripheral blood specimens were collected in EDTA-anticoagulated tubes and processed within 24 h of collection. After incubation with monoclonal antibodies for 15 min at 4°C, erythrocytes were lysed with ammonium chloride (PharmLyse; BD Biosciences, San Diego, California, USA) at room temperature for 10 min using a standard lyse/wash technique. Samples were acquired on FACS Canto II instruments (BD Biosciences). The antibody combinations used were CD14-FITC, CD30-PE, CD64-APC, CD117-PE-Cy7, CD34-PerCP-Cy5.5, and CD45-V500. The negative control contained CD34-PerCP-Cy5.5 and CD45-V500 with absence of CD30-PE.
| Results|| |
Data were collected, revised, coded and entered to Statistical Bundle for Social Science (SPSS) version 20.
Our study included10 new cases of AML patients and 10 new cases of ALL, 15 refractory/or relapsed cases of AML and15 refractory/or relapsed cases of ALL either T-cell or B-cells type.
| Discussion|| |
The objective of the present study was to assess CD30 expression of bone aspiration and/or peripheral blood by flow cytometry in patients with AML and in ALL either T-cell or B-cells type either new or refractory/relapsed cases to evaluate the benefit of anti-CD30 therapy in these groups ([Figure 1] and [Figure 2] and [Table 1],[Table 2],[Table 3]).
|Figure 1 ROC curve revealed that the accuracy of sensitivity and specificity was 69.9%.|
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|Figure 2 Kaplan–Meier estimator of the correlation between CD30 and overall survival (OS) of ALL included patients was negative correlation. ALL, acute lymphoblastic leukemia.|
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|Table 1 Comparison between patients with AML and ALL as regards CD30 expression and immunophynotyping pattern, and CD30 expression in new and relapsed cases of ALL and AML by their subtypes|
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|Table 2 Comparison between New ALL amd AML and relapsed cases of both types as CD30 expression. And between relapsed cases of both AML and ALL as regard CD30 expression|
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|Table 3 Correlation between risk parameters and CD30 expression in ALL patients|
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In this study, comparison between patients with AML and those with ALL regarding CD30 expression revealed significant difference. There was an increase in CD30 expression in patients with ALL (P<0.05). This was in agreement with Zheng et al.  who assessed CD30 expression in patients with ALL of either T-cell or B-cell lineage to examine potential benefit of anti-CD30-targeted therapy in this group of patients (1). Bone marrow specimens of 34 patients with T-ALL and 44 with B-ALL were assessed for CD30 expression by multicolor flow cytometryimmunophenotypic analysis. They detected CD30 expression in approximately one third of T-ALL patients, and less frequently in B-ALL (P=0.01). There was positive significant relation between relapsed cases T-ALL and CD30 expression, our results are in agreement with Zheng et al. (2014) who studied 78 ALL patients, 75 (96%) were adults and 63 (81%) had refractory/relapse disease. Using an arbitrary 20% cutoff, 13/34 (38%) T-ALL and 6/44 (14%) BALL cases were considered to express CD30. In Five T-ALL patients with sequential bone marrow tested, increased CD30 expression was observed during the course of high dose chemotherapy (P=0.025). In T-ALL, CD30 expression is upregulated during high dose chemotherapy. These data indicateindicate that anti-CD30-targeted therapy may be a potential option for T-ALL patients with refractory/relapsed disease.
In this results, the comparison between new and relapsed cases of both AML and ALL using immunophenotyping revealed nonsignificant differences, which was in agreement with other authors ,,.
Regarding our cases of AML, M1–M2 cases represented 90% followed by M3, which represent 10% of the cases. In contrast to this study, Gómez et al.  studied 1018 patients and reported that APL was the most frequent AML subtype (35.5%), followed by the M2 subtype (21.69%) with a statistically significant difference. Regarding ALL subtypes in our study, 70% were pre-B-ALL, 10% B-ALL and 20% T-ALL in the new cases, whereas 26.6% were pre-B-ALL, 13.3% B-ALL 33.3% pre-T-ALL, 20% T-ALL, and 6.6% pro-T-ALL in the relapsed cases, which revealed that B-cell types were the most common. In agreement with our results, Gómez et al.  reported that 93.6% were B-cell subtype, whereas the other 6.3% were T-cell subtype.
An increased MRD% in relapsed ALL cases in comparing with new cases was found but was not yet statistically significant. Comparison between new and relapsed cases of patients with AML regarding mortality rate revealed significant increase in mortality rate in newly diagnosed cases (60%) in comparison with relapsed cases (40%) (P<0.05). This increase in mortality rate in new cases just after induction chemotherapy may be attributed to acute respiratory distress syndrome or prolonged cytopenia. Moreover, comparison between new and relapsed cases of patients with ALL in the study regarding mortality rate revealed nonsignificant difference (P>0.05).
Our results disagree with Godley and Larson , who investigated a number of potential risk factors related to poor outcome of patients, including sepsis, invasive fungal infection, prolonged hospitalization, or ICU admission, which may compromise the ability of these patients to receive intensive remission induction chemotherapy or bone marrow transplantation .
In this study, we tried to compare survival in whole leukemia in relation to CD30 expression and found that elevated level of CD30 expression affect survival of our patients but not statistically significant (P=0.059). This is in agreement with El Naby et al. , who demonstrated worse survival in cases with CD30-positive expression than those with negative CD30 expression in acute leukemia.
There was a significant positive correlation between white blood cells (WBC) (>100 000), Platlets (PLT) (<30 000), and CD30 expression in patients with T-ALL in our study. Nigm et al.  also reported significant correlation between both high CD30 expression and WBCs count. They also reported that high CD30 expression and serum soluble CD30 can be used as prognostic markers for relapse and complete remission failure, respectively. Furthermore, these patients with adverse risk cytogenetics do not have too many treatment options, so the use of anti-CD30-targeted therapy may be a possible alternative for this patient group, which needs further studies.
Gong et al.  reported that CD30+ cases may have poor clinical outcomes and need the salvage therapy of anti-CD30-targeted treatment. Moreover, data suggested that CD30 expression was associated with poor survival in patients with diffuse large B cell lymphoma (DLBCL).
Gattei et al.  had found a statistically significant direct association in acute leukemias between the presence of CD30 on tumor cells and the absolute number of circulating blasts and total WBC counts, along with an inverse association with the absolute number of platelets.
These data indicate that anti-CD30-targeted therapy may be a potential option for patients with T-ALL with refractory/relapsed disease. Moreover, in this study, when we try to compare the survival in whole leukemia in relation to CD30 expression, we found increased CD30 expression affects survival of our patient.
| Conclusion|| |
The results of the current study raise the possibility that anti-CD30-targeted therapy may be a potential option for patients with T-ALL and, particularly those patients with refractory or relapsed disease.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hasserjian RP. Acute myeloid leukemia: advances in diagnosis and classification. Int J Lab Hematol
Estey EH. Acute myeloid leukemia: 2013 update on risk-stratification and management. Am J Hematol
Licht JD, Sternberg DW. The molecular pathology of acute myeloid leukemia. Hematology Am Soc Hematol Educ Program
Kamimura T, Miyamoto T, Harada M, Akashi K. Advances in therapies for acute promyelocytic leukemia. Cancer Sci
:1929–1937. doi: 10.1111/j.1349-7006.2011.02045.x. Epub 2011 Aug 24.
Koreth J, Schlenk R, Kopecky KJ et al.
Allogenic stem cell transplantation for acute myeloid leukemia in first complete remission review and meta-analysis of prospective clinical trials. JAMA
Faderal S, Kantarjian HM, Taplaz M et al.
Adult acute lymphocytic leukemia concepts and stratigies. Cancer
Chiaretti S, Zini G, Bassan R. Diagnosis and subclassification of acute lymphoblastic leukemia. Meditter J Hematol Infect Dis
Arber DA, Orazi A, Hasserjian R et al.
The 2016 revision to the World Health Organization classification of myeloid neoplasm and acute leukemia. Blood
Bassan R, Spinelli O, Oldani E et al.
Improved risk classification for risk −specfic therapy based on the molecular study of minimal residual disease in adult acute lymphoblastic leukemia. Blood
Abd El-Naby A, Gawaly A, Awni S. Novel immunophynotyping marker in acute myeloid leukemia: does it implicate prognosis? Egypt J Hematol
Wright CW, Pileri SA, Feldman AL et al.
CD30 activates both the canonical and alernative NF-κB pathway in anaplastic large cell lymphoma cells. J Biol Chem
Sotomayor EM, Young KH, Younes A. Clinical roundtable monography: CD30 in lymphoma its role in biology, diagnostic testing, and targeted therapy. Clin Adv Hematol Oncol
Zheng W, Medeiros LJ, Young KH, Goswami M, Powers L, Kantarjian HH et al.
CD30 expression in acute lymphoblastic leukemia as assessed by flow cytometry analysis. Leukemia Lymphoma
Gupta A, Pal A, Silas S. Immunophenotyping in acute leukemia. A clinical study. Int J Sci
Khalidi HS, Medeiros LJ, Chang KL et al.
The immunophenotype of adult AML: high frequency of lymphoid antigen expression and comparison of immunophenotype. FAB classification and karyotypic abnormalities. Am J Clin Pathol
Ghosh S, Agustin P, Luis AD et al.
Hemtologic and immunophenotypic profile of AML: an experience tata memorial hospital. Indian J Cancer
Gómez AD, Marcos E, Montano E et al.
Acute leukemia characteristic are different around the world: The Mexican perspective. Clin Lymphoma Myeloma Leuk
Godley LA, Larson RA. Therapy-related myeloid leukemia. Semin Oncol
Halpern AB, Culakova E, Walter RB et al.
Association of risk factors, mortality and care costs of adult with AML with admission to the ICU. Oncol
Nigm DA, Abd El Hameed ZA, Abd Elrahman MZ. CD30 expressiona vs. serum soluble CD30 (sCD30) level: role in prognosis and treatment of acute myeloid leukaemia. J Clin Cell Immunol
Gong Q-X, Lu T-X, Liu C, Wang Z, Liang J-H, Xu W et al.
Prevalence and clinicopathologic features of CD30-positive de novo diffuse large B-cell lymphoma in Chinese patients: a retrospective study of 232 cases. Int J Clin Exp Pathol
Gattei V, Massimo D, Annunziata G et al.
CD30 ligand is frequently expressed in human hematopoietic malignancies of myeloid and lymphoid origin. Blood
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]