Karyotype analysis demonstrated trisomy 3 as a sole anomaly in two out
of twenty analyzed cells. To confirm clonality of this finding
interphase FISH was performed using a chromosome 3 centromere (CEP3)
probe, which showed 25 out of 300 cells positive for trisomy 3
(Figure
4) .
Figure 4. Conventional cytogenetics (G-banded karyotype) and
fluorescence in situ hybridization (FISH) studies were performed on the
lymph node involved with PTLD. A. Chromosome analysis revealed
47,XX,+3[2]/46,XX[18]. B. This finding was confirmed by internal
FISH studies with a probe for the centromere of chromosome 3,
which detected three copies of chromosome 3 in 8.3% (25/300) of the
nuclei examined. FISH studies were performed using commercially
available Vysis Centromere 3 (CEP 3) probe (Abbott Molecular, Des
Plaines, IL), cut off value established for trisomy 3 is 1 percent.
Although bone marrow did not show histologic or immunophenotypic
evidence of the involvement by PTLD, molecular studies detected clonal
and oligoclonal T-cell gene rearrangements. Patient was treated with
Rituximab. Currently patient is seven years old, doing well and is free
of the recurrence of PTLD.
4. Discussion
PTLDs represent a heterogeneous, commonly EBV-driven clonal
proliferation of B-cells with admixed T-cell and plasma cells3. Although PTLDs are usually diagnosed based on
clinical history, morphology, and immunophenotype, clonality studies are
used to aid in the diagnosis. Cytogenetics is a powerful technique to
determine clonality and, if possible, interpret clinical implications of
the particular clone or clones. Although molecular diagnostics dominate
the era of the precision medicine, conventional chromosome analysis and
FISH studies remain valuable to diagnose gross chromosomal abnormalities
in PTLDs. Cytogenetics allows identification of a single cell that bears
aneuploidies or large chromosomal aberrations. Furthermore, FISH studies
can be utilized to confirm the clonality of findings identified by
karyotype. The most common aberrations were trisomies of chromosome 9
and/or 11 associated with EBV positivity, followed by translocations
involving 8q24.21 (MYC), 3q27.3 (BCL6), and 14q32.13 (IGH), 14q32.33
(TCL1) 15. The identification of cytogenetic markers
that either contribute to the prediction of clinical behavior or
response to the treatment are important in managing patients with PTLDs.
Although specific mutations have not been reported in PTLDs, aberrant
somatic hypermutation was implicated in a pathogenetic process that
activates protooncogenes such as such as paired box protein (PAX-5) and
avian myelocytomatosis viral oncogene homolog (C-MYC)16.
Aberrations involving chromosome 3 have been described in a range of
low-grade B-cell lymphomas including marginal zone lymphoma, with the
incidence reaching 85 percent in splenic marginal zone lymphoma17 18. Trisomy 3 has been reported
in other types of B‐cell lymphomas such as follicular lymphoma, small
cell lymphocytic lymphoma, and diffuse large cell lymphoma19. Trisomy 3 has also been described in a range of
T‐cell lymphomas 20. Chromosome 3 contains
proto-oncogenes that were reported in hematologic malignancies including
transducin (beta)-like 1 X-linked receptor 1 (TBL1XR1) at 3q26.32,
myeloid differentiation primary response gene (88) (MYD88) at 3p22.2,
GATA binding protein 2 (GATA2) at 3q21.3, ras homolog family member A
(RHOA) at 3p21.31, MDS1 and EVI1 complex locus (MECOM) at 3q26.2, T cell
leukemia translocation altered (TCTA) at 3p21.31 and BCL6 transcription
repressor (BCL6) at 3q27.3. It is possible that the pathogenesis of
PTLDs is mediated by the trisomy 3 through the increased gene dosage of
proto-oncogenes, however precise mechanism remains elusive. Recentin vitro studies using spontaneously proliferating EBV-infected
B-cells from patients with PTLD demonstrated a higher average growth
rate and expression a miR-BHRF1-3, the miRNA that was reported to have
transforming abilities 21.
One of the patients presented here (Case 1) also had one cell with a
monosomy of chromosome X in addition to trisomy 3. This finding likely
represents a subclone, or a secondary finding in addition to trisomy 3.
One of the ways that the loss of chromosome X might contribute to the
pathogenesis of PTLD is through the loss of the copy of tumor suppressor
gene. Several X-linked tumor suppressor genes including APC membrane
recruitment protein 1 (AMER1) at Xq11.2 and forkhead box P3 (FOXP3) at
Xp11.23 are X-linked tumor suppressor genes involved in prostate cancer22 23.The synchronous trisomy 3 with
an extra chromosome X has been previously reported in the pediatric PTLD12. To our knowledge, this is the first report of the
pediatric polymorphous PTLD with coexisting trisomy 3 and monosomy of
chromosome X.
In the present study, we report two pediatric cases of polymorphous
EBV-driven PTLDs with trisomy 3 arising in the setting of cardiac and
liver/intestinal allograft. In addition, one of the patients (Case 1)
had a monosomy of chromosome X. Both of the patients are doing well,
which argues against poor prognostic value of trisomy 3 in PTLDs.
Further studies are necessary to characterize cytogenetic findings in
the larger number of pediatric PTLD to understand the significance of
trisomy 3. In addition, it is important to understand the significance
of trisomy 3 with or without monosomy of chromosome X. Eventually,
better understanding of the landscape of cytogenetic abnormalities in
pediatric patients with PTLD will contribute to the accurate diagnosis
and clinical prognosis.
Author Contributions: Diagnosis, F.Q.R., J.S., S.S.;
writing—original draft preparation, A.S, N.G..; writing—review and
editing, A.S., F.Q.R.; project conception, F.Q.R.
Funding: This research received no external funding.
Acknowledgments: Authors are thankful to both patients who
contributed to this case report.
Conflicts of Interest: The authors declare no conflict of
interest.
F.Q.R. ORCID number 0000-0002-6709-6209
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