Leukemic blast cells are thought to arise from clonal expansion of a single transformed hematopoietic cell. This generality is supported by the rarity of convincing reports on acute myeloblastic leukemia (AML) with two karyotypically independent clones. Relying on sequential cytogenetic analyses, we identified such clones in two children with relapsed AML. The first case, classified as M2 leukemia in the French- American-British (FAB) classification system, had a t(8;21) (q22;q22) at diagnosis; 16 months later, at relapse, the leukemic cells had uniform morphologic features similar to those observed at diagnosis, except that two independent clones were present: one with the original t(8;21) and the other with t(11;22)(q23;q13) [corrected]). The second case was initially classified as FAB M1 leukemia with a t(8;21) (q22;q22). At relapse, 16 months later, the blast cells appeared morphologically uniform and similar to the diagnostic specimen; however, in addition to the original t(8;21) clone, there was a t(1;11) (p32;q23) [corrected]. These findings suggest that separate leukemogenic events affecting different progenitor cells can occur in rare cases of AML. The presence of two karyotypically independent clones could also be explained by multistep leukemogenesis; that is, more than one cell from a common pool of preleukemic cells could be affected by the transforming event, resulting in two independent clones. Alternatively, in light of recent reports of therapy-related leukemias with an 11q23 translocation, the new independent clone in these two patients could represent a therapy-related secondary malignancy. Thus, 11q23 translocations may occur preferentially in stem cells that are more susceptible to treatment-induced malignant transformation.

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