Biology and therapy of secondary leukaemias

Secondary leukaemias are common, accounting for more than 40% of all patien ts with acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS). A clinical history of exposure to haematotoxins or radiation is helpful; howe ver, many older patients are diagnosed with leukaemia with no antecedent hi story of exposure. These patients' disease show a remarkably similar phenot ype to classic therapy-related leukaemia. The specific cytogenetic abnormal ities common to MDS, alkylating-agent-related AML and poor-prognosis AML (3 q-, -5, 5q-, -7, 7q-, +8, +9, 11q-, 12p-, -18, -19,20q-, +21, t(1;7), t(2;1 1)), probably reflect a common pathogenesis distinct from that of other de novo AMLs, although the pathogenetic pathway has yet to be elucidated. Poss ibly, tumour suppressor genes are implicated and genomic instability may be a cause of multiple unbalanced chromosomal translocations or deletions. Ty pically, these patients are either elderly or have a history of exposure to alkylating agents or environmental exposure 5-7 years prior to diagnosis. Another distinct entity affects the mixed lineage leukaemia (MLL) gene loca ted on 11q23. These account for about 3% of patients with therapy-related l eukaemia and have a short latency period from exposure, usually to an inhib itor of topoisomerase II. Other therapy-related patients with t(8:21), invl 6 or t( 15;17) translocations should be treated as any other de novo AML wi th similar cytogenetics. In summary, the major prognostic factor is related to the pathogenetic mechanisms of the leukaemia. Cytogenetics and molecula r features are a better predictor of outcome than patient history. Patients should receive standard induction therapy. However, the long-term outcome is relatively poor; the best results being obtained among patients undergoi ng allogeneic transplantation.