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\begin{document}

\title{Clinical Features and Treatment Strategies of Precursor B-cell
Lymphoblastic Leukemia with C-myC Rearrangement in Childhood}



\author[1]{Xiang Wang}%
\author[1]{Jun Huang}%
\author[1]{kefei Wu}%
\author[1]{Lisha Yu}%
\author[1]{Ci Pan}%
\author[2]{Jing Chen}%
\author[1]{Shuhong Shen}%
\author[2]{Changcheng Chen}%
\author[1]{Qiang Mi}%
\affil[1]{Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine}%
\affil[2]{Shanghai Childrens Medical Center Affiliated to Shanghai Jiaotong University School of Medicine}%


\vspace{-1em}



  
  \date{June 15, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: ``Rare cases of Burkitt leukemia/lymphoma (BL) exhibiting a
precursor B-cell phenotype (termed herein pre-BLL) were admitted by WHO
Classification of Hematopoetic and Lymphoid Tissue, recent evidence
suggests that these neoplasms genetically and epigenetically resemble
precursor B-cell leukemia/lymphoma (pB-acute lymphoblastic
leukemia/lymphoblastic lymphoma (ALL)/LBL) rather than BL. The clinical
features and treatment of childhood pre-BLL with C-myC rearrangement are
poorly understood. Methods:The clinical features, treatment strategies
and follow-up information of 9 cases with pre-BLL diagnosed by Shanghai
Children's Medical Center affiliated to Shanghai Jiao Tong University
School of Medicine from 2011 to 2020 were retrospectively analyzed.
Results: All the 9 cases were confirmed to be pre-BLL by flow cytometry
and fluorescence in situ hybridization, morphological classification
were L2/L3, immunophenotype was CD10, CD19 positive, CD20, TDT, CD34
selective expression, sIgM negative, Kappa and Lambda light chain
negative. Most of the pre-BLL cases were accompanied by elevated lactate
dehydrogenase (LDH), uric acid levels. 5 cases received intensive
chemotherapy with overlapping regimen, and all achieved sustained
remission except for 1 case relapse and death. Among the 4 cases who
received low-intensity chemotherapy for acute lymphoblastic leukemia, 2
cases died due to early relapse of the disease. Conclusions: Pre-BLL
cases are rare. and intensive chemotherapy treatment according to
protocols for mature B-cell NHL. Currently, the treatment strategies are
still controversial. Considering the small number of cases, multi-center
clinical studies should be actively carried out to find a standard
treatment plan.%
\end{abstract}%



\sloppy


\textbf{1 _INTRODUCTION}

The rearrangement of the c-MYC gene is the hallmark of Burkitt leukemia
(BL), which is a kind of mature B-cell neoplasms, accounting for about
2\% of acute pediatric leukemia. The well characterized immunophenotype
for BL is mature B cell phenotype, including CD10, CD19, CD20, CD22,
CD79a and sIgM, without the expression of CD34 and terminal
deoxynucleotidyl transferase (TdT) \textsuperscript{1, 2}. Except for
BL, c-MYC rearrangement can also occur in other B-cell NHL, such as
diffuse large B-cell lymphoma (DLBCL), multiple myeloma (MM) and so
on\textsuperscript{3}. Nevertheless, c-MYC rearrangement is also
occasionally detected in acute lymphoblastic leukemia (ALL) with an
immature B cell immunophenotype of B cell precursor (BCP-ALL). Although
the ``WHO Classification of Tumors of Hematopoietic and Lymphoid
Tissue'' has noted these rare cases of BL exhibiting a precursor B-cell
phenotype (termed herein ``pre-BLL''), the characteristics of it are
poorly understood for its rarity\textsuperscript{4}. Because of the
overlapping features between BL and pre-BLL, the diagnosis is often
delayed and the treatment is controversial, making the clinical
management complicated. In order to clarify the clinical and biological
characteristics and the treatment outcome of pre-BLL, we report nine
patients with pre-BLL in this study.

\textbf{2 _PATIENTS AND METHODS}

Patients with pre-BLL included in this study were diagnosed and treated
in the Shanghai Children's Medical Center (SCMC) from January 2001 to
December 2020. The diagnosis was determined by cell morphology,
flow-cytometric and molecular biologic analysis. The diagnostic criteria
were based of French--American--British (FAB) classification and
European Group for the Immunological Characterization of Leukemias
criteria\textsuperscript{5, 6}. The presence of c-MYC arrangement was
confirmed by fluorescence in situ hybridization (FISH). Patient data
analyses included basic clinical information: gender, age and
extramedullary infiltration; laboratory information: white blood cell
count, serum UA, LDH level; and details of treatments and outcomes. This
study was approved by the institutional review board of the SCMC.

\textbf{3 _RESULTS}

\textbf{3.1 _Clinical characteristics of patients with pre-BLL}

Among all the patients with BCP-ALL diagnosed in SCMC from January 2001
to December 2020, nine were identified to carry c-MYC rearrangement. Two
of the nine patients were [?] 10 years old (22\%), while the other seven
were \textless{} 10 years old (78\%), with a mean age of 6.8 years
(1.5-12.8), close to the average onset age of pre-BLL of 6.1
years\textsuperscript{7}. And there were 4 male children (44\%) and 5
female children (56\%). Alongside a mature B-cell immunophenotype,
patients with BL usually have FAB-L3 morphology, and bulky disease,
elevated LDH and UA, at the high risk of tumor lysis\textsuperscript{8}.
Cytomorphologic features showed that three of nine patients had FAB-L3
morphology (3/9), four of nine patients had FAB-L2 morphology (4/9), and
the other two are not classifiable (2/9). Immunophenotypically, leukemia
blasts were uniformly stained for CD10 (9/9), CD19 (9/9) and HLA-DR
(9/9). The expression of TdT (6/9), CD34 (1/9), CD20 (3/9) and c\selectlanguage{greek}μ \selectlanguage{english}(1/9)
was variable. All the patients lacked the expression of sIgM and
negative for kappa/lambda. The white blood cell counts at diagnosis were
variable (mean 44,009/mm\textsuperscript{3}; range
710-199,450/mm\textsuperscript{3}). All but one patient had markedly
increased serum LDH three times higher than baseline. One of nine
patients had bulky disease (1/9). Liver and/or spleen (5/9) and lymph
nodes (5/9) were frequently affected. Two patients had central nervous
system (CNS) involved (2/9). In addition, one patient had other organs
involved, including kidney, pancreas and intestinal wall. The patient
with kidney involved was accompanied by renal failure and continuous
renal replacement therapy (CRRT) was used at the initial stage of
chemotherapy. Tumor lysis syndrome was encountered in induction
chemotherapy by two patients, and were corrected soon (Table 1).

\textbf{3.2 _Treatments and outcomes}

Four preBLL patients were initially treated according to B-NHL/ALL
protocols for mature B-cell leukemia from the beginning. Two courses of
rituximab were administered to one of them because of the early
termination of therapy for recurrent intracranial fungal abscess.

One patient received induction treatment according to protocols for
BCP-ALL for 71 days and switched to B-NHL/ALL courses. In three
patients, intensive treatment was followed by ALL-type maintenance
therapy. Relapse occurred in one patient after 5 months since diagnosis,
and the other four patients had maintained completed remission (CR)
until the last follow-up. The other four patients were treated according
to BCP-ALL protocol\textsuperscript{9}, and two of them relapsed after 7
months and 19 months since diagnosis, respectively (Figure 1).

\textbf{4 _ DISCUSSION}

C-MYC has been described as a proto-oncogene that is involved in the
pathogenesis of many cancers, including leukemia and lymphoma.
Physiologically, c-MYC plays an important role in B-cell differentiation
and proliferation. During the maturation of B cell, c-MYC base levels
are maintained and its transient downregulation is required at some
specific point to promote the proliferation of
B-cell\textsuperscript{10, 11}. The most common c-MYC rearrangement is
reciprocal chromosomal translocation between 8q24 and 14q32, followed by
8q24 with t(8;22)(q24;q11), and t(2;8)(p12;q24)\textsuperscript{12}. The
translocation places the c-MYC gene under direct regulation of the
enhancer of the IGH (or IGK/IGL genes), causing overexpression of c-MYC
gene\textsuperscript{13}.

Although it is mainly observed in mature B-cell neoplasms, c-MYC gene
rearrangement can occasionally detected in patients with BCP-ALL
immunophenotype. Previous published researches have shown that pre-BLL
is a rare subtype comprising 0.1\% (5/5280) of BCP-ALL in the Pediatric
Oncology Group (POG) and 0.2\% (10/4043) in a nationwide study in
Japan\textsuperscript{14, 15}. Our data also indicates that pre-BLL is
rarely detected in clinic, and comprising \textasciitilde{}0.5\% of all
the B-NHL and BCP-ALL.

Kimiyoshi Sakaguchi et al. had conducted the literature survey to
further shed light on the clinical and immunological features of pre-BLL
compared to BCP-ALL\textsuperscript{15}. Compared to his research, we
failed to observe a relatively older median age (6.8y) and a higher UA
level (6.93mg/dl) of our patients, but we could observe an elevated
level of LDH (median \textgreater{}5,700 IU/l), which was consistent
with other researches. The blast immunophenotypes reported in other
researches were similar to that of our patients.

With the improvement in standard chemotherapy and supportive care, the
outcome for pediatric BL and BCP-ALL has improved with a 5-year overall
survival (OS) rates achieve 90\%\textsuperscript{16, 17}. Despite with
the immunophenotype of BCP-ALL and the genetic characteristic of BL, the
biological characteristics and treatment of pre-BLL are still
controversial. By using next generation sequencing (NGS), Wagener et al.
have uncovered that pre-BLL shows similar molecular features of BCP-ALL
rather than BL, with recurrent NRAS/KRAS mutations, lack of functional
B-cell receptor and c-MYC translocation due to aberrant VDJ
recombination, instead of class switch or somatic hypermutation like
mature B-cell neoplasms\textsuperscript{18, 19}. Whereas protocols for
BL consist of short-course and high-intensity pulsed chemotherapeutic
regimen, protocols for BCP-ALL are characterized by continuous treatment
regimen with a long-term maintenance therapy of low intensity. Based on
the literature survey and several cases, Herbrueggen et al. encouraged
treatment of pre-BLL according to protocols for mature B-cell NHL rather
than BCP-ALL\textsuperscript{3}. In this study, five patients were
treated with mature B-cell neoplasm protocols and one (1/5) relapsed in
a short time (5 months). Among the other four patients who was treated
with BCP-ALL protocols, two (2/4) relapsed before termination of
treatment. It is suggested that the outcomes of pre-BLL patients appear
to be favorable when treated with protocols used for mature B-cell
neoplasm. Sakaguchi et al. have suggested that high-risk ALL-type
treatment might be adequate for the treatment of
pre-BLL\textsuperscript{15,} but there is still inconclusive how
intensive the chemotherapy should be.

Although with a molecular similarity to BCP-ALL, the presence of the
c-MYC warrants intensive treatment due to the highly proliferate nature
of pre-BLL. However, the intensity of chemotherapy, the value of the
supplemented of targeted~drug like rituximab and the necessity of
maintenance therapy are still unknown. Some patients relapsed even when
treated with high-intensity regimen, suggesting further genetic studies
should be performed. In view of the rarity of pre-BLL, international
collaborative efforts are encouraged to further elucidate the biological
and clinical characteristics of pre-BLL and finally establish a
consensual treatment approach.

\textbf{ACKNOWLEDGMENTS}

We gratefully acknowledge the work of whole members of Department of
Hematology and Oncology, Shanghai Children's Medical Center, Shanghai
Jiao Tong University School of Medicine

\textbf{CONFLICTS OF INTEREST}

There are no competing financial interests.

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