RE: FISH test

March 27, 2003

In a message dated 3/27/03 1:36:33 PM Pacific Standard Time,

camlo2k@... writes:

> This study may indicate a better intellectual and/or

> behavioral outcome with the proximal vs. the common 22q11 deletion,

> rather than a chance finding.

Carol,

Thank you so much for the information. 's behavioral development is

normal, and intellectually he is well above average. For years his Cardio

argued with me because he speaks using such big words, even at a very young

age. This article helps make sense of the situation!! Since I first joined

this group, Diane pointed out to me that Tetrology of Fallot was a hallmark

sign of Di. Then, add an immune deficiency, and well, I guess if it

walks like a duck... Finally his Cardio decided that a FISH test was a good

idea, based on his immune problems.

What type of immune issues does Maya deal with? Does she have any T-cell

problems?

Sandi--Mom to , age 10. Immune Deficiency of unknown origin, Tetrology

of Fallot, chronic sinusitis, chronic ear infections, asthma, severe

allergies, GERD. Heart surgery pending.

March 27, 2003

Hi there, as you know Maya has Di with a negative fish on chromosome

22. I got this information from the VCFS/Di group and you may find

this useful if he too tests negative on the FISH test. I haven`t got round

to finding out if this is available for testing in the UK but I know it is

in the US.

Di/velocardiofacial syndrome: FISH studies of chromosomes 22q11

and 10p14, and clinical reports on the proximal 22q11 deletion.

Bartsch O, Nemeckova M, Kocarek E, Wagner A, Puchmajerova A, Poppe M,

Ounap K, Goetz P.

Institut fur Klinische Genetik, Medizinische Fakultat Carl Gustav

Carus, Technische Universitat Dresden, Dresden, Germany.

Di anomaly/velocardiofacial syndrome (DG/VCFS) occurs with

different deletion intervals on chromosomes 22q11, while the Di

anomaly (with other findings) is seen in patients with deletions of

10p14. The clinical outcome with the common 22q11 deletion (90% of

cases) is well known, but the outcome with the less frequent deletion

types has not been well documented. Using cytogenetic and

fluorescence in situ hybridization (FISH) analysis we studied a

series of 295 patients with suspected DG/VCFS. We identified 58

subjects with a 22q11 deletion, and none with a 10p deletion. Fifty-

two subjects had the common deletion, five had the proximal deletion,

and one had an atypical proximal deletion due to a 1;22

translocation. We report clinical data of four subjects with the

proximal 22q11 microdeletion, and of one patient with the atypical

proximal deletion. The anomalies observed with the proximal 22q11

microdeletion fell within the DG/VCFS spectrum. Two females, 6 and 25

years old, had normal mental development. Normal development has been

reported with the common 22q11 deletion, but only in a minority of

cases. This study may indicate a better intellectual and/or

behavioral outcome with the proximal vs. the common 22q11 deletion,

PMID: 12548732 [PubMed - in process]

Carol

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July 22, 2004

From what I can tell, the F.I.S.H. (Flourescence in situ Hybridization) test is

used to distinguish MCL from " indolent lymphomas and leukemias " . It involves

Cyclin D1 and translocation of genes (11:14). It was the test that determined

that I did NOT have MCL but have SLL instead (after having been diagnosed

locally with MCL). You can check the following website and see if it makes any

sense: http://www3.mdanderson.org/depts/pathology/fish/cyclin/.html

You might also try the Leukemia and Lymphoma Society website for links. Good

luck! Bettie from Tallahassee

FISH test

What does it mean if the FISH test results show no markers? Is

this a sign that it is not CLL or another leukemia? Any info on

this would be appreciated.

July 23, 2004

Hello philadellphis,

No, I'm sorry, if the FISH panel doesn't show any markers it does not mean

you do not have CLL, but it does indicate quite a good prognosis.

There is some very good information on this on the CLLtopics web site

(www.clltopics.org). Search for FISH or look at the articles " What Type of

CLL Do You Have "

(http://www.clltopics.org/PI/what_type_of_cll_do_you_have.htm) and

" Fishing for Answers "

(http://www.clltopics.org/PI/Fishing%20for%20answers.htm)

( " What Type of CLL Do You Have " also includes information on how CLL is

diagnosed.)

Here is my layman's explanation of what I understand the FISH test to be.

(Please excuse my ham-handed explanation. I hope it's reasonably accurate,

but I'm not a medical man.)

The FISH test is a method of looking at DNA. There is an awful lot of

information in the DNA. When FISH tests are done they are used to look at

specific small bits of it. For example, if we want to see if there is a

bit missing from the end of chromosome 17 a probe is used which would

attach itself to the very end of the chromosome on the side we are

interested in. Then we look at the result and see if we can see the probe.

If we can see the probe then the end of chromosome 17 must be there. If we

cannot see the probe we can assume the end of chromosome 17 is missing.

(This is a very crude explanation, but it should suffice to roughly explain

the process.)

I believe when FISH is used for CLL patients a " panel " of 4 different

probes is generally used. These are pointed at 4 bits of the DNA which

research has shown are of interest in CLL cases. These are not the only

abnormalities related to CLL, just the ones that we know enough about for

it to be worth testing for.

Some of the abnormalities indicate a poorer prognosis. (for example a 17q

deletion) From what I have read about these 4 markers patients with the

best prognosis have the 13q deletion and no other abnormalities. The next

best result is no abnormalities showing, as in your case.

If I am right there must be a genetic abnormality for the cancer to exist.

But maybe the scientists haven't found the bit that has gone wrong in your

case or they don't know enough about what it means for it to be worth

testing for it.

If you haven't used the clltopics web site before then it is really worth

having a look at. Don't be daunted by the amount of information, it's

much to much to try to take in quickly. Start with the introduction (A CLL

Primer) and if you feel you want to know more about something in the future

go back and look it up. I have found it invaluable.

Tim Meaddows (husband of CLLer dx 12/2003 age 35, stage 0 W & W)

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February 12, 2005

To the best of my knowledge, it is a blood test. Anyone else? Kurt?

February 12, 2005

Blood test...... Regards..... Walter V.......

Date: Sat, 12 Feb 2005 10:51:37 -0600

From: BayouPointe <BayouPointe@...>

Subject: FISH test

I haven't yet had a FISH test and was wondering if this is a blood

test or is it a bone marrow biopsy. Could someone who has had it

please let me know?

Thanks.

February 12, 2005

This may help you understand the test.

Gordon Dobler

FISH-ing for Answers

March 6, 2004

by Venkat

The old ways are changing. But if you read any of the short and sweet patient

information brochures and on-line write-ups, the ones that do not update their

content on a regular basis, you could come away with the impression that the

" Watch & Wait " approach is still the unquestioned best way to treat CLL

patients. CLL Topics begs to differ. Slowly but surely, that approach ruled by

the one-size-fits-all perspective is giving way to more risk-adapted therapy

decisions in treating CLL patients. Sure, you will still find old school local

oncologists who have not kept up with the latest information and would prefer to

stick to the old ways. In that case, it is up to you to read, understand and

decide for yourself and perhaps change your oncologist's perspective as well.

In this article I will present my take on the following:

The rationale for FISH (Fluorescence In-situ Hybridization) testing.

Review of quotations from CLL experts, focusing on their evaluation of the role

of modern FISH analysis in therapy decisions. If you wish to read the full

journal articles from which I extracted the quotations, write to us at and we

will help you locate the articles.

The need for annual repeat FISH analysis.

Details of who does the FISH test, what to look for in the test, contact

information you can give your doctor to order the test, ball-park costs, and

last but not least, how to get it done without traveling to a major cancer

center.

Background

The Rai and Binet classification systems have been the underpinnings of CLL

treatment for more than a decade. They provided a rational way of looking at the

disease, a yardstick with which to measure the level of tumor load and therefore

a rational way of deciding when to end the " Watch & Wait " phase. In their time,

they were both extremely useful in guiding therapy decisions. We have discussed

the details of the Rai and Binet staging in a previous article. We have also

reviewed many of the modern prognostic indicators that are useful in segregating

CLL patients into different risk categories in our article " What Type of CLL do

you have? " . If you have not read it before, I urge you to do so now. In that

article we discussed the role of IgVH gene mutation status, CD38 levels on CLL

cells, and ZAP-70 as well as other popular indicators.

The bad news is that tests such as IgVH gene mutation status and ZAP-70 are

still not available commercially, and there is still a degree of controversy on

how exactly they relate to each other and to the other prognostic indicators.

The jury is still out on CD38 expression, some experts think this changes over

time just like B2M (concurrently with the disease), and therefore is not a good

indicator of future prognosis.

The good news is that the specific chromosomal aberrations you have are at the

very heart of what makes your CLL tick and many of the other prognostic

indicators are derivatives of this fundamental cytogenetic flaw. A few years

ago, " FISH CLL panel " was an expensive procedure carried out only at top-rated

research labs. But now, modern FISH analysis is rapidly becoming a standardized

test. Unfortunately it is still not a fully FDA-approved test procedure, not

yet. However, it is feasible right now to get this test done, if you are willing

to " push " the issue. I am willing to bet FISH analysis will be within reach of

most of us in the next year or two, fully approved by the FDA and as automatic

as a regular CBC.

The following is a link to a PDF document form the National Human Genome

Research Institute. It provides background on FISH testing.

http://www.accessexcellence.org/AB/GG/nhgri_PDFs/fish_TXT.pdf

Rationale for FISH Testing Ahead of Therapy Decisions

This is where rubber meets the road. Life was simple a decade ago, when there

were few diagnostic tools and fewer therapy choices. Watch-and-wait was a good

strategy then since there was no point in undergoing high toxicity chemotherapy

before you absolutely needed it to take care of nasty b-symptoms, especially

since it did not add to overall survival. Ten years from now, life may get

simple again, with better understanding of the exact nature and risks of each

variety of CLL matched with well defined and optimized therapy strategies for

patients in the different risk groups. Right now we are in that uncomfortable,

in-between stage. The technology is available, the research findings are pretty

clear and we can differentiate patients into different risk " buckets " with a

reasonable degree of confidence. What is missing is the general percolation of

this information and insight down to the level of the local healthcare provider

and the insurance companies that sometimes use the FDA

lethargy in the approval process as a fig leaf for not covering reasonable

procedures. Several years ago, there was no choice. But for patients today,

making therapy choices without knowing their chromosomal aberration can be the

equivalent of shooting in the dark. You may get lucky, but there is also the

chance that you may end up shooting yourself in the foot or some other place

where it hurts even more.

Let's make this discussion up close and personal. You have recently been

diagnosed with CLL. The shock is just wearing off and you are now in the

learning mode, trying your best to come to grips with the situation. The monthly

CBC says your absolute lymphocyte count is not all that high and you have a

couple of lymph nodes that are just beginning to bump out. No fevers or

infections, no night sweats, no B-symptoms yet, thank your stars. Old school

conventional wisdom says do nothing and stay in Watch-and-wait mode until you

start feeling the effects of the disease and your shirt collar no longer fits

because of expanding nodes under your jaw, until you have to change your PJ's in

the middle of the night because of night sweats, or until CLL-related fatigue

gets you out of having to invent excuses for not attending to the honey-do list.

When you reach that stage, the old-schoolers tell you, that is when you initiate

fludarabine therapy, the current gold standard for CLL.

Is this the right choice? That depends. If you were lucky enough to have one of

the more benign chromosomal aberrations, say a sole 13q deletion which puts you

squarely in Bucket A, this approach is not a bad one. You get to delay the

inevitable day of therapy for as long as possible - and when you can no longer

put it off, fludarabine will probably work well for you. But what if you were

not one of the lucky ones? What if you did not have a sole 13q deletion and

instead you had the dreaded 17p deletion (deletion of the TP53 tumor suppressor

gene)? Would it still be prudent to let the CLL tumor load get ever higher, with

lymph nodes to match? Would fludarabine still be the right choice as front-line

therapy? In the next section I would like to lay out the logic that says it

would not be a good choice to wait out a 17p deletion case till the disease

becomes bulky and fludarabine is most likely not the best choice in such a case.

How can you tell what to do and when to do it, if you

don't even know what type of CLL you have in the first place? That is the

nature of this debate.

What the Experts Say

Dohner, Stilgenbauer, et. al., provide some of the first clear indications of

cytogenetics and response to conventional therapy. Fifty patients received

therapy with purine analogs (fludarabine or pentostatin). The response to

therapy depended strongly on the presence of a 17q (TP53 gene) deletion. None of

the 12 patients with 17q deletion responded to therapy with fludarabine (7

patients) or pentostatin (5 patients), while 20 out of 36 (56%) patients without

a deletion achieved a remission. The median survival time after start of therapy

in the patients with a p53 gene deletion was only 7 months, whereas the median

survival time of the patients without a deletion had not yet been reached at 72

months.

If you were one of the unlucky ones with TP53 deletion as your chromosomal

aberration, two points stand out - you are not likely to respond to fludarabine

or pentostatin (another purine analog similar to fludarabine); and once therapy

starts, you may not have a lot of time to re-think options and implement a brand

new game plan.

As you can read below, options other than fludarabine or pentostatin may be your

best bet. If you were one of these unfortunate Bucket C folks and you followed

the conventional wisdom of yesteryear, by staying in Watch-and-wait until onset

of heavy duty B-symptoms and then treating with fludarabine, in my opinion you

would be up the proverbial creek without a paddle. Standard chemo drugs may not

work well for you, and by that time your lymph nodes may be so large that the

monoclonals have a hard time doing the job adequately (see " Campath Looking

Better and Better " ). How would you know what to do, whether or not you have the

17p (TP53 gene) deletion, unless you get the FISH test done at the time of

diagnosis?

Abstract:

Blood. 1995 Mar 15;85(6):1580-9.

p53 gene deletion predicts for poor survival and non-response to therapy with

purine analogs in chronic B-cell leukemias.

Dohner H, Fischer K, Bentz M, Hansen K, Benner A, Cabot G, Diehl D, Schlenk R,

Coy J, Stilgenbauer S, et al.

Medizinische Klinik, University of Heidelberg, Germany.

Conventional cytogenetic analysis in B-cell chronic lymphocytic leukemia (B-CLL)

has been very difficult, and the prognostic significance of specific chromosome

aberrations is under discussion. Recent improvements in fluorescence in situ

hybridization (ISH) techniques have provided an alternative approach for the

detection of chromosome aberrations. Here, an interphase cytogenetic study was

performed to analyze the incidence and prognostic significance of a p53 gene

deletion in B-CLL and related disorders. We studied mononuclear cells from 100

patients with chronic B-cell leukemias [b-CLL, 90 patients; B-prolymphocytic

leukemia (B-PLL), 7; Waldenstrom's macroglobulinemia (WM), 3] by fluorescence

ISH with a genomic p53 DNA probe. In a subset of patients, additional G-banding

analysis and single strand conformation polymorphism (SSCP) analysis was

performed. Seventeen of the 100 patients [17%; B-CLL], 11 of 90 (12%); WM, 1 of

3; B-PLL, 5 of 7] exhibited a monoallelic p53 gene deletion

by ISH. G-banding analysis demonstrated abnormalities of chromosome 17 in 13 of

these 17 patients, all leading to loss of band 17p13. SSCP analysis showed

aberrant bands in 9 of 14 patients with a p53 gene deletion. None of 12 patients

with a p53 gene deletion compared with 20 of 36 patients (56%) without a

deletion responded to therapy with fludarabine or pentostatin (P < .001). The

difference in survival probabilities from the time of diagnosis and from the

start of treatment with purine analogs between the two groups was highly

significant (P < .001). In multivariate analysis, p53 gene deletion was the

strongest prognostic factor for survival. In conclusion, p53 gene deletion

predicts for non-response to therapy with purine analogs and for poor survival

in chronic B-cell leukemias.

PMID: 7888675

____________

Below is another blue-blood pedigree paper that comes to the same conclusion.

Byrd, Flinn et al have provided one of the first analysis of response to Rituxan

as a function of the FISH cytogenetic type. Unfortunately, the sample size is

rather small, with as few as 3-4 patients in some of the categories, making the

statistics less than robust. Nevertheless, this study does make a couple of

important points: one of the poor prognosis groups, those with 11q (ATM gene)

deletion, do respond well to Rituxan, while those with the 17p (TP53 gene)

deletion do not respond to Rituxan. Perhaps this stance will be modified as

larger retrospective studies are done. This is what the authors have to say, in

terms of applying the new paradigm to better treat CLL patients:

" How can these results be applied to the treatment of patients with CLL? The

data described herein extend the observation of others regarding the

chemoresistance of del(17)(p13.1) to also include rituximab. This contrasts with

preliminary findings of Stilgenbauer et al., who demonstrated in a small series

that CLL patients with del(17)(p13.1) had clinical responses to Campath-1H. If

the findings of Stilgenbauer et al. are confirmed in larger cohorts of patients,

it would appear that Campath-1H, as opposed to fludarabine, chorambucil, or

rituximab would be a more rational initial treatment choice for patients with

del(17)(p13.1). This will be particularly true if new combination regimens of

rituximab and fludarabine or fludarabine, cyclophosphamide, and rituximab cannot

overcome the resistance associated with del(17)(p13.1). Studies examining this

important clinical question are currently under investigation by our group. "

I find the quote above from their paper almost a valuable as the actual

statistics. This is the first clear-cut connection between therapy choices such

as fludarabine, chlorambucil, Rituxan and Campath and cytogenetics voiced by

some of the best minds in the business. Based on their results the authors

conclude even Rituxan is not a good choice for the 17p deletion types, Campath

may be better choice for them. And the authors leave the door open but raise the

million dollar question, what about combination therapies like the popular " FRC "

and " FR " ? Would 17p deletion folks who do not respond to fludarabine, would they

respond to fludarabine containing combos? Good question, don't you think? If you

had 17p deletion, you would certainly want to know the answer, before you signed

up for these combinations, I would think. If you did not even know your FISH

cytogenetics, how do you even begin to make smart therapy choices? Just imagine,

would you want to go through all the significant

pain and toxicity of one of these therapies, if you had an only slim chance of

getting a good response from the get go?

Too bad the sample size in this pivotal paper is small, it is time we got some

clear answers to these very important questions. The authors say studies

examining these clinical questions are currently under investigations in their

lab. A heartfelt Amen! to that from this reporter and CLL spouse.

Abstract:

http://cancerres.aacrjournals.org/cgi/content/full/63/1/36

Cancer Res. 2003 Jan 1;63(1):36-8.

Interphase cytogenetic abnormalities in chronic lymphocytic leukemia may predict

response to rituximab.

Byrd JC, L, Hackbarth ML, Flinn IW, Young D, Proffitt JH, Heerema NA.

The Division of Hematology-Oncology, Ohio State University, Columbus, Ohio

43210, USA.

Select cytogenetic abnormalities such as del(17)(p13.1) and

del(11)(q22-q23)predict rapid disease progression and inferior survival in

chronic lymphocytic leukemia (CLL). We sought to determine the impact of the

four most common interphase cytogenetic abnormalities in 28 CLL patients

relative to response to three-times-a-week rituximab therapy. Abnormalities were

noted in 25 of the 28 patients to include del(13)(q14.3) [n = 16 (57%)],

del(11)(q22.3) [n = 10 (36%)], +12 [n = 6 (21%)], del(17)(p13.1) [n = 5 (18%)],

and normal [n = 3 (11%)]. Only a minority of each of these occurred as sole

abnormalities. To categorize patients into one specific group, we used the

hierarchical order del(17)(p13.1) > del(11)(q22.3) > trisomy 12 > del(13)(q14.3)

to prioritize. Response to rituximab was noted to vary by cytogenetic group:

del(17)(p13.1), 0% [n = 5]; del(11)(q22.3), 66% [n = 9]; del(13)(q14.3), 86% [n

= 7]; +12, 25% [n = 4], and normal, 0% [n = 3]. Response was significantly lower

(P =

0.05) in patients with del(17)(p13.1) as compared with those with other

abnormalities. These data suggest that interphase cytogenetics in CLL may be

predictive of a response to rituximab therapy and provide support for additional

studies validating risk-adapted therapy in this disease.

PMID: 12517774

______________

I will wrap up this section with a discussion of the third paper I would like to

bring to your attention. This time the experts are of the caliber of Flinn,

Grever, Byrd et al, no slouches in the whole pack. This article is focused on

Campath, the other big monoclonal antibody in the CLL universe. The authors

agree that while ZAP70 and IgVH mutation status are interesting and important,

it is still the cytogenetics that are likely to have the most direct correlation

to clinical outcome. Unlike purine analogs such as fludarabine and pentostatin,

Campath was found to have significant activity even in 17p deleted " Bucket C "

patients. The quote below is from the full paper, and the highlighted sentence

says it in blunt terms. Fludarabine, chlorambucil, even Rituxan, may not be

rational choices as therapy for 17p (TP53 gene) deleted patients, Campath would

be a better choice.

" How can these results be applied to the treatment of patients with CLL? While

recently identified prognostic factors such as VH mutational status and

associated ZAP-70 expression are predictive of disease progression and inferior

survival, one preliminary study did not relate this to resistance to

conventional CLL therapies. This contrasts with del(17)(p13.1)/p53 abnormalities

that become increasingly common with disease progression and are associated with

resistance to most conventional therapies used in the treatment of CLL. The data

described support the case report of Stilgenbauer and colleagues who

demonstrated a complete response in a single CLL patient with del(17)(p13.1) and

p53 mutation. Similar to the results reported in this single case report,

several patients included in our series had durable remissions that ranged from

3 to 17 months with three having complete eradication of the del(17)(p13.1)

clone in the bone marrow post-therapy. If our collective findings are

confirmed in larger prospective cohorts of patients, it would appear that

alemtuzumab, as opposed to fludarabine, chorambucil, or rituximab would be a

more rational initial treatment choice for patients with p53 mutations and/or

del(17)(p13.1). In addition, these data would provide preliminary evidence for

screening all patients at time of initial and subsequent therapies for the

presence of del(17)(p13.1) and p53 mutations to avoid administration of

otherwise ineffective therapy for this disease. "

Abstract:

Blood. 2004 Jan 15

Alemtuzumab is an Effective Therapy for Chronic Lymphocytic Leukemia with p53

Mutations and Deletions.

Lozanski G, Heerema NA, Flinn IW, L, Harbison J, Webb J, Moran M, Lucas M,

Lin T, Hackbarth ML, Proffitt JH, Lucas D, Grever MR, Byrd JC.

Pathology, The Ohio State University, Columbus, OH, USA.

The presence of p53 mutation or deletion predicts for poor response to

conventional therapy in chronic lymphocytic leukemia (CLL). We sought to

determine if the humanized anti-CD52 antibody alemtuzumab was effective in this

patient group. Thirty-six patients with fludarabine refractory CLL were treated

with alemtuzumab, fifteen (42%) of which had p53 mutations or deletions.

Clinical responses in patients with p53 mutations and/or deletions were noted in

6 of 15 (40%) versus 4 of 21 (19%) of patients without. The median response

duration for this subset of patients was 8 months (range 1-17 months). These

data suggest that alemtuzumab may be an effective therapy for CLL patients with

p53 mutations or deletions.

PMID: 14726385

______________

You might ask, what is wrong with trying out fludarabine even with a 17p (TP53

gene) deletion, the worst that can happen is that you don't get a good response

and you may have to raise the stakes and move on to Campath. Well, the risk is

higher than just not getting a good response. TP53 gene and the ATM gene are the

gatekeepers of your genome. You can read a lot more about them on our recent

article, " Cytogenetics of ATM and P53 " . When these two important genes are not

working well, you can make the situation a lot worse by exposure to DNA-damaging

agents such as fludarabine. The following is an oversimplification, but it helps

to make the point: chemotherapy drugs such as alkylating agents (chlorambucil,

cyclophosphamide) and purine analogs (fludarabine, pentostatin) work by causing

severe DNA damage to cancer cells. The damage is often so severe that the cells'

own internal mechanisms kick in and order the cells to die. The problem is that

two of the most important internal

mechanisms we are talking about are functions of the ATM and TP53 genes. In

other words, with poor functioning of the ATM and TP53 gene, not only is the

damaged cancer cell not ordered to kill itself, it may in fact continue living

in its even more mangled and damaged form. What does this mean to the patient?

One of the consequences could be risk of secondary cancers down the road, such

as multiple myeloma. The abstract below by on, Rai, et. al., describes

potential risks of this type.

Please be sure you get this point right: just because you have had fludarabine

therapy and you have also got ATM and/or TP53 gene defects does not guarantee

that you will have secondary cancers. It may, however, mean you have a higher

risk of developing these secondary cancers than patients with similar

cytogenetics who were not exposed to DNA-damaging drugs. Cancer is all a matter

of statistics and balancing risk / reward ratios. If you are looking for

absolute answers and guarantees, this website may not be your cup of tea and

perhaps you had better invest in a crystal ball! And do me a favor, please do

not shoot the messenger if I am bringing you bad news.

Abstract:

J Clin Oncol. 2002 Sep 15;20(18):3878-84.

Therapy-related myeloid leukemias are observed in patients with chronic

lymphocytic leukemia after treatment with fludarabine and chlorambucil: results

of an intergroup study, cancer and leukemia group B 9011.

on VA, Rai KR, BL, Kolitz JE, Elias L, Appelbaum FR, Hines JD,

Shepherd L, Larson RA, Schiffer CA.

Section of Hematology/Oncology, Veterans Affairs Medical Center, Minneapolis, MN

55417, USA.

PURPOSE: Patients with chronic lymphocytic leukemia (CLL) may have disease

transformation to non-Hodgkin's lymphoma or prolymphocytic leukemia; however,

development of therapy-related acute myeloid leukemia (t-AML) is unusual. A

series of patients enrolled onto an intergroup CLL trial were examined for this

complication.

PATIENTS AND METHODS: A total of 544 previously untreated B-cell CLL patients

were enrolled onto a randomized intergroup study comparing treatment with

chlorambucil, fludarabine, or fludarabine plus chlorambucil. Case report forms

from 521 patients were reviewed for t-AML.

RESULTS: With a median follow-up of 4.2 years, six patients (1.2%) to date have

developed therapy-related myelodysplastic syndrome (t-MDS; n = 3), t-AML (n =

2), or t-MDS evolving to t-AML (n = 1), from 27 to 53 months (median, 34 months)

after study entry. This included five (3.5%) of 142 patients treated with

fludarabine plus chlorambucil and one (0.5%) of 188 receiving fludarabine; no

chlorambucil-treated patients developed t-MDS or t-AML (P =.007). At study

entry, the median age among these six patients was 56 years (range, 44 to 72

years); three were male; the CLL Rai stage was I/II (n = 4) or III/IV (n = 2).

Response to CLL therapy was complete (n = 4) or partial remission (n = 1) and

stable disease (n = 1). Marrow cytogenetics, obtained in three of six cases at

diagnosis of t-MDS or t-AML, were complex, with abnormalities in either or both

chromosomes 5 and 7. Other abnormalities involved chromosomes X, 1, 8, 12, 17,

and 19. Median survival after diagnosis of t-MDS/AML was 3.5

months (range, 0.5 to 10.1 months).

CONCLUSION: Our findings raise the possibility that alkylator-purine analog

combination therapy may increase the risk of therapy-related myeloid

malignancies, which is of particular relevance with regard to ongoing trials

using these combination therapies.

PMID: 12228208

______________

The Need for Repeat FISH Analysis on a Regular Basis

Hopefully I have convinced you by now that getting a FISH analysis done is of

major importance in determining your therapy choices. But why do you have to

repeat it? Is it not enough to know once and for all what " Bucket " you belong

to, and that is that? Not quite. CLL is not a static business. It evolves and

changes over time. In some patients who have a truly smoldering disease, nothing

much happens. They most often have the relatively benign 13q deletion going in,

and they stay with that for the rest of their natural lives. Others, like our

hypothetical patient Harvey ( " The Difficult Case of the Round-headed Kid " )

undergo clonal evolution. Harvey too had a 13q deletion going in, clearly a

resident of the lucky " Bucket A " . His game plan was to stay cool, not worry too

much about stuff because he had every option in the book available to him when

he needed it, including the high response FRC type combo therapies. Then one

fine day as a result of an annual FISH test he discovered his

CLL clone had " evolved " . A new variant raised its ugly head that had both the

13q deletion as well as a more dangerous 11q deletion added to it. Another

repeat FISH analysis a few months later confirmed the more dangerous " double

trouble " clone with both 11q and 13q deletions was rapidly gaining ground over

the clone with just the 13q deletion. His game plan had to be changed - purine

analogs were not his best bet anymore and he had to make sure he could get by

with just monoclonals. For starters this meant he had to make sure his disease

never got too bulky, since monoclonals do have a hard time dealing with bulky

lymph nodes. Suddenly, he experienced a higher level of interest in " mobilizing

agents " that can flush out the CLL cells from lymph nodes and bone marrow.

What happened to Harvey can happen to any patient. I do not know of any way to

prevent clonal evolution, short of curing the underlying CLL. The best you can

do is to monitor the situation. If the situation changes on you, and you have

been lucky enough to find out about it in good time, you will be able to make

the necessary course corrections. Fore-warned is fore-armed. You can read the

technical abstracts and the logic of getting repeat FISH testing done at least

on an annual base in our recent article on clonal evolution.

Where to Go, How to Get It Done

The " CLL FISH panel " test is not yet formally approved by the FDA. But then,

neither is Rituxan approved as frontline and single agent therapy for CLL, and I

think a lot of you have gotten over that hurdle. It does mean though that you

have to work with your insurance companies and healthcare providers to get this

test done and have it covered under your insurance policy. That part is up to

you, but I will make this general comment: you get nothing if you are not even

willing to ask, and it is amazing what you can get if you are willing to be

determined and organized in your campaign. Contrary to popular thinking, the

world out there does not think it owes you a free lunch.

We have identified two companies that will do the CLL FISH panel, which includes

testing for 13q deletion, 12 Trisomy, 11q deletion and 17p deletion. These are

the four major chromosomal aberrations under scrutiny right now. No doubt others

such as 6q deletion will be added as time goes on. Make sure your test includes

testing for each of these four major cytogenetic abnormalities. The cost of

doing the test is approximately $450 dollars, roughly the same for both the

labs. As I said above, you might want to make sure you know ahead of time how

much of this your insurance will cover.

In addition to the two listed below, you might find that other providers are

able to meet this need. If you obtain additional information on other providers

or on applicable insurance coverage, please let us know by email: . Widespread

adoption of the test, FDA approval and competition from additional providers

should make the cost more affordable and the insurance coverage better. But it

all starts with you talking to your oncologist.

A. Mayo Medical Laboratories

Cytogenetics Laboratory

Test # 83089, CLL FISH Panel (Cost $412.00)

Not approved by the FDA: Insurance carriers may not recognize this as a covered

benefit.

Additional information: Carlson, Supervisor, Cytogenetics Lab,

507-266-5349

Business Office for Billing Questions 1- 800-533-1710

It is possible to get the blood sample drawn locally, and then sent to Mayo Labs

for testing.

You can get a lot more information from Mayo Medical Labs website:

http://216.245.167.14:81/MALHTML/83089.html

The site gives precise instructions on sample size of blood, how it is to be

collected, stored and shipped to the Mayo lab. It is important that your local

blood draw station follows the instructions exactly, it is not a bad idea to

print out the instructions and take them with you. If necessary, the supervisor

at the draw station can call Mayo Labs on the phone and get clarifications. Make

very sure the sample is sent over by the fastest mode, say FedEx overnight. It

is suggested that you do not get the blood drawn on a Friday or even late in the

week, since you would not want the sample languishing unattended over the

weekend. The normal reference range, based on a 95% confidence interval, is

<6.5%, <5.0%, <7.0%, and <8.5% for deletion in 6q, 11q, 13q, or 17p,

respectively; <1.5% for trisomy 12. What that means is that if the percent of

CLL cells with a particular abnormality is below the cutoff threshold, the test

will not be able to measure it with a reasonable level of

confidence.

If your doctor recommends a FISH analysis of bone marrow aspirate, Mayo Labs can

do that as well. Again, go to the website and make sure you and your doctor

follow the instructions precisely. Since the accuracy of the test does depend on

getting a good and well preserved sample to the testing lab, it is in your

interest to make sure it is done right.

B. Labcorp: Center for Molecular Biology and Pathology

CLL FISH Panel. LabCorp test #510594 (Cost $416.50)

Not approved yet by FDA; Because test is new it may not be recognized by

carriers as a covered benefit for patients.

CLL FISH panel available targeting ATM (11q), 12 trisomy, 13q, and 17p (TP53) .

Source of Information: Jeanetta (919-361-7700)

For additional information call 800-735-4087

General company web address as well as the one specific to the oncology section

are given below. You will have to scroll down almost to the bottom of the page

for the oncology section before you get to the relevant information for CLL FISH

panel.

http://www.labcorp.com/dos/index.html

http://www.labcorp.com/datasets/labcorp/html/frontm_group/frontm/section/profonc\

..htm

For more information, call Oncology Customer Service at Labcorp at 800-533-0567.

Editorial

Someone told me there is an ancient Chinese curse that goes like this " May you

live in interesting times " . We are certainly living in interesting times, and it

is not always a great deal of fun. Those of us who have been cursed by this

disease for a while remember the not-so-good old days, when names like Rituxan

and Campath were hardly ever heard. FISH was something you ordered for dinner,

and good old Leukeran pills were the mainstay of CLL therapy. No choices, no

decisions, no hassle. One size fits all. One third of all CLL patients smoldered

for the rest of their natural life, one third needed treatment and did fine for

some time with the chemotherapy drugs of the day, one third had no luck from the

get go, nothing available worked for them. I wonder, did this very approximate

segregation of CLL patients into thirds match our now more sophisticated

" Buckets " , did they pretty much follow the cytogenetic and other prognostic

indicators we have now figured out?

Now things are a lot more complicated, but also a lot more optimistic. The third

of the patients who were lucky to start with, they are still lucky and they can

check their FISH status periodically and make sure their luck is holding. The

middle group can try and finesse the situation, see if they can get by with less

toxic and longer lasting therapy choices. We now know that roughly a quarter to

a third of all CLL patients have the poor prognosis 11q and 17p deletions right

from the beginning, or evolve into that position at a later date. These are the

ones with massive lymph nodes, rapidly increasing counts and resistance to most

chemotherapy drugs. In the past, they had short survival and complicated disease

progression to look forward to. That is what has changed, thanks to better

understanding of the underlying chromosomal aberrations. Once we figured out the

function of ATM and TP53 genes, and that their malfunction is involved in 11q

and 17p mutations and deletions, the

emphasis is to keep away from further DNA damaging agents. Monoclonal

antibodies, vaccine approaches, bone marrow transplants and the like have a much

better chance of giving good results.

What about the patients who have already crossed the bridges, made the therapy

choices that perhaps were not optimal for them, in the light of present day

information? We can all play Monday morning quarterbacks, but there is little to

be gained by going over could-haves and should-haves, or shooting the messenger

that brings you bad news. Time can only go forward, and we all have to live with

the choices we have made along the way, make the best of our today and our

tomorrows. This website is dedicated to helping CLL patients find better

solutions for themselves. It is not equipped to give detailed or specific

medical advice. We cannot turn the clock back, invent miracle drugs, pills or

potions, nor can we cure your CLL. What we can do is to find and present

information that you can use, in a form that may be more useful to you as

laypersons. It is up to you to make use of the information, to the extent that

you and your healthcare team think appropriate.

This page printed from:

- http://www.clltopics.org/PI/Fishing%20for%20answers.htm

BayouPointe <BayouPointe@...> wrote:

I haven't yet had a FISH test and was wondering if this is a blood

test or is it a bone marrow biopsy. Could someone who has had it

please let me know?

Thanks.

February 12, 2005

Thanks so much for the information.

On Sat, 12 Feb 2005 13:22:16 -0800 (PST), Gordon Dobler

<gj628dobler@...> wrote:

>

> This may help you understand the test.

>

> Gordon Dobler

> FISH-ing for Answers

> March 6, 2004

>

> by Venkat

>

> The old ways are changing. But if you read any of the short and sweet patient