Oddballs: Acute Leukemias of Mixed Phenotype and Ambiguous Origin




Historically, acute leukemias that do not fit neatly into the broad categories of “acute myeloid leukemia” or “acute lymphoblastic leukemia” have caused considerable confusion and frustration for clinicians and pathologists. These misfit cases include bilineage and biphenotypic leukemias (collectively termed “mixed phenotype acute leukemias” in the 2008 World Health Organization Classification of Tumors of Hematopoietic and Lymphoid Tissues), as well as acute undifferentiated leukemias and other miscellaneous atypical cases. In this review, the author discusses the definitions, history, clinical behavior, and current treatment approaches to acute leukemias of Sambiguous lineage.


Using currently available diagnostic tools, skilled hematopathologists can assign most pediatric and adult acute leukemias to myeloid, B-lymphoid, or T-lymphoid lineages without much difficulty. However, a subset of more challenging cases (depending on the particular criteria used for lineage assignment, this subset may represent as many as 5% of all acute leukemias) cannot be easily classified, despite integration of data from flow cytometric, immunohistochemical, cytochemical, cytogenetic, and molecular genetic investigations.


This uncommon and heterogeneous group of acute leukemias has received a degree of attention disproportionate to its prevalence, and has been described using a variety of terms: bilineage , biphenotypic , hybrid , polyphenotypic , mixed lineage , mixed phenotype , ambiguous lineage , uncertain origin . The most recent (2008, fourth edition) World Health Organization (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues includes 7 categories of varying specificity within an “acute leukemias of ambiguous origin” diagnostic group, including bilineage and biphenotypic leukemias, which are classified together as “mixed phenotype acute leukemias” (MPAL) ( Table 1 ). The WHO ambiguous-origin leukemias also include an “other ambiguous lineage leukemias” category, which contains a provisional entity, “natural killer cell lymphoblastic leukemia/lymphoma,” as well as 2 categories defined by both immunophenotype and by one of a pair of specific molecular genetic findings, BCR-ABL fusion and MLL rearrangement. With the exception of BCR-ABL1 fusion, the oncogenic protein product of which can be inhibited using targeted tyrosine kinase inhibitors, the clinical relevance of the other WHO-defined ambiguous leukemia distinctions remains unclear.



Table 1

World Health Organization (WHO) 2008 (4th edition) classification of “acute leukemias of ambiguous lineage”




























Category Definition and Comments
Acute undifferentiated leukemia An acute leukemia that does not express any marker that is considered specific for either lymphoid or myeloid lineage . a Nonhematopoietic tumors (eg, germ cell tumors) and acute leukemias of unusual lineage (eg, those derived from myeloid or plasmacytoid dendritic cell precursors, NK-cell precursors, basophils) must be excluded. Blasts may express HLA-DR, CD34, or CD38 and may be positive for TdT.
Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1 An acute leukemia that meets diagnostic criteria b for MPAL, in which the blasts also have the t(9;22) chromosome translocation or the BCR-ABL1 rearrangement . Patients known to have had chronic myeloid leukemia before developing blast phase should not be assigned to this category, even if they meet diagnostic criteria for MPAL.
Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged An acute leukemia that meets diagnostic criteria b for MPAL, in which the blasts also have a translocation involving the MLL gene at 11q23 . Cases of ALL that express myeloid antigens but do not meet criteria for MPAL should not be assigned to this category.
Mixed phenotype acute leukemia, B/myeloid, NOS An acute leukemia that meets diagnostic criteria for assignment to both B and myeloid lineage , in which the blasts lack genetic abnormalities involving BCR-ABL1 or MLL
Mixed phenotype acute leukemia, T/myeloid, NOS An acute leukemia that meets diagnostic criteria for assignment to both T and myeloid lineage , in which the blasts lack genetic abnormalities involving BCR-ABL1 or MLL
Mixed phenotype acute leukemia, NOS – rare types An acute leukemia with a mixed phenotype that is not listed above. Examples would include a lymphoid leukemia with both B and T lineage commitment, or a leukemia with evidence of trilineage (ie, B/T/myeloid) markers. Erythroleukemias and megakaryocytic leukemias are clearly of myeloid origin, but do not typically express MPO, so B/ or T/erythroleukemia, or B/ or T/megakaryocytic leukemia, if they exist (they had not yet been described at the time of the 2008 WHO classification, but a case report of B/erythroleukemia appeared shortly thereafter ), would fit in this category.
Other ambiguous lineage leukemias An acute leukemia that expresses an unusual combination of markers that does not allow classification as either AUL, MPAL, or a single lineage leukemia ( eg, a form of AML or ALL) using WHO diagnostic criteria c for lineage assignment.
This category includes a rare provisional entity: (Precursor) natural killer cell lymphoblastic leukemia/lymphoma, which expresses CD56 along with immature T-associated markers, and lacks B-cell and myeloid markers as well as T-cell clonal gene rearrangement. CD94 1A and CD161 might be expressed, but currently are rarely tested in clinical practice.

Abbreviations: ABL1 , Abelson tyrosine kinase 1; ALL, acute lymphoblastic leukemia; BCR , breakpoint cluster region; CD, cluster of differentiation/designation; MLL , mixed lineage leukemia; MPAL, mixed phenotype acute leukemia; MPO, myeloperoxidase; NK, natural killer; NOS, not otherwise specified; TdT, terminal deoxynucleotidyl transferase.

Data from Borowitz MJ, Béné MC, Harris NL, et al. Acute leukaemias of ambiguous lineage. In: Swerdlow SH, Campo E, Harris NL, et al, editors. World Health Organization (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues, 4th edition. Lyon (France): International Agency for Research on Cancer (IARC) Press; 2008. p. 150–5.

a By definition, acute undifferentiated leukemias lack cytoplasmic CD3 (T lineage defining), lack MPO (myeloid lineage defining), do not express B-cell–specific markers (eg, cytoplasmic CD22, cytoplasmic CD79a, or strong expression of CD19), and lack specific features of other lineages, such as plasmacytoid dendritic cells, erythroblasts, or megakaryocytes. For further discussion of lineage-specific markers, see Tables 2 and 3 and relevant text.


b Diagnostic criteria for “mixed phenotype acute leukemia” require assignment of blast cells to 2 or 3 lineages, using lineage-defining criteria in Table 3 . Mixed phenotype may result from either 2 distinct blast cell populations or 2 or more lineage-associated markers on the same blast cells.


c These cases must be distinguished from blastic plasmacytoid dendritic cell neoplasm (BPDCN), which was not clearly part of the 2001 WHO classification but is included as a distinct entity in the 2008 WHO classification. BPDCN tumor cells express CD4, CD56, CD43, CD45RA, and the plasmacytoid dendritic cell neoplasm markers CD123, CD303 (BDCA2), TCL1, CLA, and MxA; 50% of cases express CD68, whereas CD7, TdT, and CD33 expression are common. Names used in the past for this neoplastic entity (BPDCN) include the following: blastic NK cell lymphoma, agranular CD4+ NK cell leukemia, blastic NK leukemia/lymphoma, or agranular CD4+ CD56+ hematodermic neoplasm/tumor. These cases also must be distinguished from myeloid/NK cell acute leukemia, which is a form of AML with minimal differentiation, possibly of precursor NK cell origin (but early NK cells express no specific markers).



The general perception among clinicians is that whether they appear in adults or children, leukemias of ambiguous origin are as difficult to treat successfully as they are to classify definitively ( Fig. 1 ). Indeed, in most published series, outcomes are poorer for leukemias of ambiguous origin than for more typical cases of acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL), and allogeneic hematopoietic stem cell transplantation is commonly offered to transplant-eligible patients, albeit more as an act of desperation in the face of extremely high relapse risk than as a data-driven care choice. Improved treatment approaches will almost certainly require moving beyond immunophenotyping and cytochemistry, and toward better understanding of the molecular pathobiology of these uncommon disorders. The evolution of diagnostic criteria, current understanding, and potential approaches to therapy for leukemias of ambiguous lineage are reviewed in this article.




Fig. 1


Photomicrographs of ( A ) Wright-Giemsa–stained bone marrow aspirate (original magnification ×400), ( B ) hematoxylin and eosin–stained bone marrow core biopsy (original magnification ×100), and ( C ) myeloperoxidase (original magnification ×400) (MPO) immunohistochemistry with Wright-Giemsa counterstaining of a marrow aspirate from a 34-year-old man who presented with a hemoglobin of 4.6 g/dL, platelet count of 82 × 10 9 /L, and a white blood cell count of 11 × 10 9 /L with 20% circulating undifferentiated blasts. The aspirate ( A ) and core biopsy ( B ) samples indicated a 60% cellular marrow with 71% blasts; the blasts exhibited scant cytoplasm, prominent nucleoli, and occasional cytoplasmic granules. MPO staining ( C ) highlighted normal neutrophils and MPO-positive blasts (brown cytoplasm), which comprised more than 3% of the total blast population; numerous MPO-negative blasts were also visible. Blasts were negative for both specific and nonspecific esterase by cytochemistry, and negative for periodic acid-Schiff (PAS) staining. Flow cytometry of the marrow aspirate ( D ; 6 representative scattergrams) revealed a population of immature cells positive for CD45 (dim), CD34, terminal deoxynucleotidyl transferase (TdT, small subset), and both myeloid lineage-associated markers (ie, MPO, CD33, and CD117) and T-cell markers (ie, cytoplasmic CD3 and CD7). The cells were negative for HLA-DR, CD13, CD15, and other monocytic, B and T lymphoid markers. Karyotyping failed at the time of diagnosis; fluorescent in situ hybridization (FISH) tests were negative for BCR-ABL fusion and MLL gene rearrangement, and subsequent karyotypes were normal. The final diagnosis using the WHO classification was “Acute leukemia of ambiguous origin, mixed phenotype acute leukemia, T/myeloid, not otherwise specified.” The patient was treated with 2 cycles of an acute myeloid leukemia chemotherapy regimen, daunorubicin and cytarabine, because of the MPO positivity, to which he did not respond, but he achieved remission with high-dose cytarabine. He was then referred to our center for consideration of allogeneic stem cell transplantation and underwent transplantation from an unrelated donor with busulfan and cyclophosphamide conditioning, which resulted in a brief remission. After relapse (similar immunophenotype), the patient received clofarabine without response, then combination chemotherapy with mitoxantrone and etoposide and high-dose cytarabine, a donor lymphocyte infusion, and a second full transplant with a different donor, all without achieving durable remission.

( Courtesy of Olga Pozdnyakova, MD, PhD, Department of Pathology, Brigham & Women’s Hospital, Boston, MA.)


Historical developments and diagnostic criteria


Developments Before 1991


Because lineage infidelity in leukemic blasts could not be described until lineage-associated markers became widely available, recognition of the more peculiar varieties of leukemia is, in the history of hematological oncology, a relatively recent development. This development is closely tied to the advent of routine cytochemical evaluation of marrow specimens in the 1970s, introduction of monoclonal antibodies in the early 1980s, and increasing use of multiparameter flow cytometry in leukemia phenotyping during the late 1980s and early 1990s.


Before 1980, clinicians and morphologists assigned leukemia diagnoses on the basis of clinical presentation and cell morphologic features, such as the cytoplasmic appearance and presence or absence of Auer rods, supplemented by basic cytochemical stains, such as Sudan Black B, chloroacetate esterase, and the periodic acid-Schiff reaction. The lineage and corresponding cytologic appearance and immunophenotype of blast cells in acute leukemia was believed to cleanly reflect malignant transformation and maturation arrest at a particular stage of hematopoietic differentiation, with acute lymphoid malignancies originating in lymphoid progenitors and acute myeloid malignancies originating in early myeloid series cells.


Several observations in the 1980s challenged this assumption, however. Expression of the terminal deoxynucleotidyl transferase (TdT) enzyme, thought to be an exclusive marker of lymphoid lineage for several years following its discovery by McCaffrey and colleagues in blasts from children with ALL in 1973, was found by 1981 to occur in 10% to 20% of cases of AML. (In fact, if more sensitive techniques are used, TdT activity is detectable in blasts in as many as 55% of AML cases, albeit usually at a much lower level of expression than is typically seen in TdT-positive ALL. ) Similarly, in the 1980s morphologists also learned that myeloperoxidase (MPO) expression, considered to be a myeloid lineage-defining marker after its initial description in the 1940s, is detectable by either cytochemistry or immunohistochemistry in more than 20% of B-ALL cases.


Additionally, in the late 1970s and early 1980s, a series of case reports and small series appeared in which investigators described detecting either 2 distinct populations of blasts of differing putative origin simultaneously in the same patient (“bilineage” leukemias), or a homogeneous population of blasts expressing markers of more than one lineage (“biphenotypic” leukemias). The relationship between bilineage and biphenotypic leukemias remained unclear, and in some instances leukemic blasts that expressed markers most suggestive of one cell differentiation program at the time of initial diagnosis would subsequently exhibit a different immunophenotype consistent with another lineage at relapse (eg, B-cell ALL at diagnosis, but AML without lymphoid lineage markers at relapse following ALL-directed chemotherapy).


In 1985, Mirro and colleagues assessed 123 consecutive pediatric leukemia cases diagnosed at St Jude Children’s Research Hospital in Memphis, Tennessee, or in Calgary, Alberta, Canada, using a panel of myeloid and lymphoid-associated antibodies, and found that ALL blasts coexpressed at least one myeloid marker in 19% of cases, whereas the leukemic blasts in 25% of AML cases expressed at least one lymphoid-associated marker. Although this landmark study highlighted the frequency of lineage infidelity in leukemia, the antibodies used to assign lineage in the study by Mirro and colleagues (ie, CD2 [T-11 antibody], CD3e [T-3], CD5 [T-101], and CD10 [J5 CALLA] for lymphoid; CD11b [Mo1 antibody], CD13 [MCS.2 and SJ-D1], CD15 [My-1], and CD36 [5F1] for myeloid) would, with the exception of CD3e, no longer be considered lineage-defining markers.


Investigators compiling adult leukemia series soon noted that a large proportion of patients with AML or ALL express at least one lineage infidelity marker, but that the presence of only a single such antigen does not alter clinical behavior or response to treatment. Further complicating matters, some markers initially thought to be tightly lineage-associated later proved to be so commonly expressed in malignancies of other lineages as to no longer even be considered aberrant. One such example is the CD15 carbohydrate adhesion molecule, which is expressed on normal neutrophils and on blast cells in most AML cases so was once considered myeloid-associated, but is also very commonly detected in B-cell ALL lacking CD10 expression and in other non-myeloid neoplasms (eg, Hodgkin lymphoma).


Development of European Group for the Immunologic Characterization of Leukemias Criteria


A growing number of case reports and small series in the 1980s highlighted increasing diagnostic confusion related to mixed lineage acute leukemias, and the need for more formal definitions of these somewhat puzzling disorders became increasingly clear. Catovsky and a group of European colleagues proposed the first scoring system for defining biphenotypic acute leukemia (BAL) in 1991, which weighed various cytochemical/immunohistochemical and immunophenotypic markers according to their perceived lineage specificity.


In 1995, the European Group for the Immunologic Characterization of Leukemias (EGIL) refined this 1991 system ( Table 2 ) to make it somewhat more stringent, requiring a lineage-associated marker score of more than 2 points in each of 2 lineages to define BAL, as well as demoting several markers that Catovsky and colleagues had proposed as supporting lineage assignment (ie, immunoglobulin heavy chain gene rearrangement for B lineage; CD11b/c and CD12 for myeloid lineage) while adding or refining several others (ie, CD20 and CD79a for B lineage; TdT, CD1a, CD7, CD8, and CD10 for T lineage; CD13, CD64, and CD65 for myeloid lineage). The EGIL system was modified in 1998 to add CD117 as a putative myeloid-specific marker, but soon a few ALL cases were found that expressed CD117.



Table 2

European Group for the Immunologic Characterization of Leukemias (EGIL) scoring system for biphenotypic acute leukemias, 1998 version
























Score B Lineage T Lineage Myeloid Lineage
2 points

  • •

    Cytoplasmic CD79a


  • •

    Cytoplasmic IgM


  • •

    Cytoplasmic CD22



  • •

    CD3 (cytoplasmic or membrane)


  • •

    T cell receptor (α/β or γ/δ)



  • •

    Myeloperoxidase


  • •

    Lysozyme

1 point

  • •

    CD19


  • •

    CD10


  • •

    CD20



  • •

    CD2


  • •

    CD5


  • •

    CD8


  • •

    CD10



  • •

    CD13


  • •

    CD33


  • •

    CD65


  • •

    CD117

0.5 point

  • •

    TdT


  • •

    CD24



  • •

    TdT


  • •

    CD7


  • •

    CD1a



  • •

    CD14


  • •

    CD15


  • •

    CD64


More than 2 points from 2 different lineages defines biphenotypic acute leukemia.

Abbreviations: CD, cluster of differentiation/designation; IgM, immunoglobulin M; TdT, terminal deoxynucleotidyl transferase.

Data from Béné MC, Castoldi G, Knapp W, et al. Proposals for the immunologic classification of acute leukemias. European Group for the Immunologic Characterization of Leukemias (EGIL). Leukemia 1995;9(10):1783–6; and Bene MC, Bernier M, Casasnovas RO, et al. The reliability and specificity of c-kit for the diagnosis of acute myeloid leukemias and undifferentiated leukemias. The European Group for the Immunologic Classification of Leukemias (EGIL). Blood 1998;92(2):596–9.


Clinicians and investigators quickly raised concerns about the EGIL criteria, such as the lack of specificity of certain EGIL-proposed markers, especially CD79a expression for defining B lineage and MPO positivity for defining myeloid lineage. In addition, the EGIL system used varying and arbitrary thresholds of cellular antigen expression required to qualify as “positive” (eg, 20% for most markers, but 10% for MPO, CD3, TdT, and CD79a), did not distinguish between biphenotypic and bilineage leukemia, did not assess intensity of antigen expression, and also failed to incorporate cytogenetic data. The latter proved to be a particularly troublesome limitation, because leukemia subtypes that were already well defined by routine G-banded karyotyping by the time the EGIL system was introduced (and, later, were further clarified using molecular genetic techniques) often express a degree of lineage infidelity, yet have other uniform features or may respond similarly to therapy regardless of immunophenotype. For example, t(8;21) AML often expresses a subset of B-cell antigens, whereas acute promyelocytic leukemia (APL), especially the hypogranular variant, frequently expresses T-cell markers, particularly CD2, and T-cell marker expression in APL has no effect on response to all-trans retinoic acid therapy. In addition, CD79a can be found in both T-ALL and myeloid leukemia, so lacks the B-cell specificity accorded to it by the EGIL system.


World Health Organization Criteria: Third and Fourth Editions


In the third edition of the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues proposed in 1999 and published in 2001, the WHO working group included a 2-page description of a classification of “acute leukemias of ambiguous lineage,” composed of 3 categories: bilineage, biphenotypic, and undifferentiated acute leukemias. Although the third edition WHO classification referenced the 1995 EGIL system (with the 1998 CD117 addition), the WHO third edition text unfortunately included a typographical error in its Table 4.03, stating that only 2 points, rather than more than 2 points, were necessary to assign a leukemia case to a given lineage. In one series, these slightly less stringent criteria tripled the number of cases defined as biphenotypic compared with EGIL criteria, and the reassignment was of dubious clinical value.


Perhaps because of this debacle, the 2008 fourth edition of the WHO classification did away with lineage scoring entirely in favor of descriptive but relatively specific requirements for assigning more than one lineage to a single blast population ( Table 3 ). Although the WHO fourth edition classification retained the category of acute leukemias of ambiguous lineage, the updated system also incorporated 5 major changes with respect to the third edition classification.



Table 3

2008 World Health Organization criteria for defining lineage assignment in acute leukemia




















Lineage Criterion #1 Criterion #2
B lineage Strong CD19, plus at least 1 of CD79a (cytoplasmic or membrane), cytoplasmic CD22, or surface CD10 also strongly expressed Weak CD19, plus at least 2 of CD79a, cytoplasmic CD22, CD10
T lineage Cytoplasmic expression of CD3 (detected by flow cytometry with antibodies against the epsilon chain of CD3 a ) Surface CD3 (rare)
Myeloid Myeloperoxidase positivity in >3% of blasts (detected by flow cytometry, immunohistochemistry, or cytochemistry) At least 2 of the following monocytic differentiation markers: CD11c, CD14, CD64, lysozyme, nonspecific (butyrate) esterase

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Sep 16, 2017 | Posted by in HEMATOLOGY | Comments Off on Oddballs: Acute Leukemias of Mixed Phenotype and Ambiguous Origin

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